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Professional Issues

What’s new with the DSM-5-TR?

By Aaron L. Norton September 29, 2022

Diagnostic and Statistical Manual of Mental Disorders, image via Flickr

Image via Flickr http://bit.ly/2lfWuka

Traditionally, our holistic emphasis on a wellness model as opposed to a medical model has been touted as a unique aspect of our professional identity as counselors. Many counselors feel more comfortable with humanistic, existentialist and postmodern theories that seem to clash with the medical model. The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA), is one of the most salient symbols of that model, so why should we care about it?

The ability to diagnose using a medical model is integral to much of what we want for our profession, such as Medicare parity, licensure portability, fair and equal access to psychological tests, and integrated care. For this reason, counseling associations have advocated relentlessly for state legislators to include the diagnosis of mental disorders in the scope of practice of licensed counselors.

According to the National Conference of State Legislature’s Scope of Practice Policy website, 36 states and U.S. territories specifically include diagnosis in behavioral health providers’ scope of practice, and an additional 19 states and U.S. territories neither empower nor prohibit counselors from diagnosis.

This diagnostic power conferred by the state comes with great responsibility, and the 2014 ACA Code of Ethics calls on counselors to diagnose properly (see Standard E.5.a.). The DSM is the most widely recognized diagnostic system for mental disorders. Although the DSM is imperfect and flawed, and there are alternative ways of conceptualizing mental health, it is nonetheless important for counselors to have a working knowledge of it.

In the following sections, I explore some common questions counselors have about the latest edition, the DSM-5-TR, which was published in May.

 

Why DSM-5-TR? Why not DSM-6?

The “TR” stands for “text revision.” Essentially, this means that APA intended to update the research components of the text and clarify some of the diagnostic criteria, but there were not enough advances in the field to support the need for the creation, revision and elimination of multiple disorders. The DSM-5 was published in 2013, and the research and statistical data contained in the manual are now outdated. The DSM-5-TR provides updated data consistent with research published since 2013.

How was DSM-5-TR developed? Were any counselors involved?

The DSM-5-TR revision started in the spring of 2019, and the final version was published in March. The DSM-5-TR specifically includes counselors in a list of professionals the text was written for, but were any counselors involved in the revision itself?

Over 200 multidisciplinary subject matter experts were involved in the revision — 64% psychiatrists, 30% psychologists and just 6% “other health professionals.” The text states that “many professional and educational groups were involved in this development and testing of DSM-5, including physicians, psychologists, social workers, nurses, counselors, epidemiologists, statisticians, neuroscientists, and neuropsychologists.” It is unclear how many counselors were involved in the revision, but it does not appear that many were.

Three primary groups were involved in the revision, including the DSM-5 Task Force, DSM Steering Committee and Revision Subcommittee. Experts were divided into 20 disorder review groups, each headed by a section editor. Four cross-cutting review groups (culture, sex and gender, suicide, and forensic) recommended updates throughout the text. Revisions were approved by the APA Board of Trustees, and public feedback was solicited and considered.

Are there any new disorders in DSM-5-TR?

There is only one new disorder in the DSM-5-TR: prolonged grief disorder. It is an updated version of a disorder that we saw in Section III of the DSM-5 (i.e., the section that describes conditions being considered for future editions of the DSM) called persistent complex bereavement disorder. It can now be found in Section II of the DSM-5-TR in the “Trauma and Stressor-Related Disorders” chapter because it is considered a reaction to a trauma or stressor.

The diagnosis of prolonged grief disorder is conceptualized as an intense longing or yearning, often with intense sorrow and emotional pain, for a deceased person close to the bereaved client, accompanied by preoccupation with thoughts or memories of the deceased person. It can only be applied if:

  • the deceased person died more than 12 months ago (for adults) or 6 months ago (for children and adolescents);
  • the client has a persistent grief response present on most days “to a clinically significant degree” (e.g., intense longing/yearning for the deceased, preoccupation with thoughts and memories of the deceased);
  • at least three of eight specified symptoms (i.e., identity disruption, marked sense of disbelief about the death, avoidance of reminders about the death, intense emotional pain, difficulty reintegrating into relationships and activities, emotional numbness, feeling that life is meaningless, and intense loneliness) have been present most days to a clinically significant degree;
  • symptoms cause clinically significant impairment or distress;
  • duration and severity of bereavement clearly exceed social, cultural or religious norms; and
  • the disturbance is not better explained by another disorder or the effects of one or more substances.

Its prevalence is unknown, but the DSM-5-TR references a rate of 9.8% with little clarity about that statistic (i.e., whether it is cross-sectional or a lifetime or perhaps 12-month prevalence rate).

Critics of the new disorder voice concerns that grief is being pathologized. Proponents, however, point out that only a small percentage of bereaved clients would meet the diagnostic criteria, the criteria clearly represent an unusual response to grief, individuals who meet criteria respond to specialized therapeutic approaches (i.e., prolonged grief disorder therapy) while their peers with uncomplicated bereavement require less intervention, and those individuals need professional help that might be difficult to access without the construct of a diagnosis.

What about racism, discrimination and cultural considerations? Anything new?

A cross-cutting review committee on cultural issues consisting of 19 U.S. and international-based experts in cultural psychiatry, psychology, and anthropology and an ethnoracial equity and inclusion work group of 10 mental health practitioners from diverse ethnic and racialized backgrounds with expertise in disparity-reduction practices were involved in the development of the DSM-5-TR. Because of their work, several semantic changes were made to the text, including the following:

  • The terms “race” and “racial” were replaced by “racialized” to highlight the socially constructed nature of race.
  • The term “ethnoracial” was used to denote U.S. Census Bureau categories Hispanic, white, or African American that combine ethnic and racialized identifiers.
  • The terms “minority” and “non-white” were avoided, as these terms infer that white is hierarchical to other racial identities, thus perpetuating social hierarchies.
  • The term “Latinx” replaced Latino/Latina in an effort to be sensitive to individuals who do not identify with binary gender markers. This revision may be lauded by transgender advocates but could also be frustrating to many Hispanic Americans who view the term Latinx as a form of colonialist intrusion into their language. Polling data from the Pew Research Center in December 2019 revealed that 76% of Hispanic adults had never heard of the term Latinx, 20% had heard it but didn’t use it, and only 3% used the term. According to an article published in Politico in December 2021, nearly half of Hispanic Americans view the term Latinx as offensive, so the two largest Spanish-speaking television networks in the country opted to replace Latinx with Latino and Latina. In an article published in The Conversation in September, Melissa Ochoa, an assistant professor of women’s and gender studies, reported that the governments of Argentina and Spain released public statements banning use of the term Latinx in July, and the term “Latine” has emerged as a more suitable gender-neutral term to replace the terms Latino and Latina because it does not violate rules of the Spanish language. It will be interesting to see whether Latinx or Latine becomes more widely accepted with time.
  • The term “Caucasian” was replaced with “non-Latinx white.”
  • Throughout the DSM-5-TR, prevalence data on specific ethnoracial groups has been included when possible.

What other disorder-related changes were made?

Some relatively minor changes (most of which are semantic) were made for a few other disorders. In my opinion, one of the most important changes involves the creation of diagnostic codes for suicidal behavior and nonsuicidal self-injury, which will allow for more effective tracking of these conditions. Other changes include the following:

  • The DSM-5 contained two sets of codes next to each disorder: the International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes. Because all U.S. health care providers regulated by the Health Insurance Portability and Accountability Act were supposed to transition to ICD-10 codes on Oct. 1, 2015, the ICD-9 codes have all been removed from the text.
  • The Criterion A phrase “as manifested by the following” for autism spectrum disorder was replaced with “as manifested by all of the following” to maintain high diagnostic threshold.
  • Disruptive mood dysregulation disorder was clarified as diagnosable between ages 6 and 18.
  • The note “witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures” in Criterion A2 of posttraumatic stress disorder was removed for children 6 years and younger due to redundancy.
  • The phrase “with relatively intact reality testing” was removed from attenuated psychosis syndrome, and symptoms were described more accurately.
  • A new set of severity descriptors was added to bipolar disorder.
  • The phrase “reduced orientation to the environment” for delirium was replaced with “accompanied by reduced awareness of the environment.”
  • Conversion disorder was renamed as functional neurological symptom disorder.
  • Several terms related to gender dysphoria were altered. Specifically, “desired gender” was replaced with “experienced gender,” “cross-sex medical procedure” was replaced with “gender affirming medical procedure,” “cross-sex hormone treatment” was replaced with “gender affirming hormone treatment,” “natal male” was replaced with “individual assigned male at birth,” “natal female” was replaced with “individual assigned female at birth,” and “differences in sex development” was noted as an alternative term for “disorders of sex development.”
  • For intellectual disorder, renamed intellectual developmental disorder, clarification was provided that although one should not be bound narrowly to the 65-75 IQ score range, the diagnosis would not be appropriate for those with substantially higher IQ scores.
  • For major depressive disorder, the Criterion D phrasing “The occurrence of the major depressive episode is not better explained by schizoaf­fective disorder” was changed to “At least one major depressive episode is not better explained by schizoaffective disorder and is not superimposed on schizophrenia.”
  • Narcolepsy subtypes were revised to harmonize with the third edition of the International Classification of Sleep Disorders and ICD-11.
  • Olfactory reference disorder (olfactory reference syndrome), which the DSM-5 referred to as “Jikoshu-kyofu,” replaced other specified obsessive-compulsive and related disorder to dispel the misunderstanding that the disorder only occurs in Japan.
  • In the third example of other specified bipolar and related disorder, the line “if this occurs in an individual with an established diagnosis of persistent depressive disorder (dysthymia), both diagnoses can be concurrently applied during the periods when the full criteria for a hypomanic episode are met” was deleted because of a conflict with Criterion E for persistent depressive disorder, which states in part that “there has never been a manic episode or a hypomanic episode.”
  • Manic episode superimposed on a psychotic disorder was added as the fifth example of other specified bipolar and related disorder with the intention of being used when other psychotic disorders from the exclusion criterion for Bipolar I and Bipolar II disorders (i.e., schizophrenia, delusional disorder, psychotic disorder not otherwise specified) do not have mood episodes as part of their diagnostic criteria, leaving no way for the mood episodes to be accounted for by the diagnosis.
  • The DSM-5 example of “attenuated delirium syndrome” under other specified delirium was replaced with “subsyndromal delirium.”
  • “Major depressive episode superimposed” was added as a fourth example of other specified depressive disorder for use when a major depressive episode occurs concurrent with a psychotic disorder that does not have mood episodes as part of its diagnostic criteria.
  • The sentence “individuals with atypical anorexia nervosa may experience many of the physiological complications associated with anorexia nervosa” was added to the description of the atypical anorexia nervosa example of other specified feeding or eating disorder to clarify that the presence of physiological consequences during presentation does not mean that the diagnosis is the (typical) anorexia nervosa.
  • In the fourth example of other specified schizophrenia spectrum and other psychotic disorder, the phrase “delusional symptoms in partner of individual with delusional disorder” was changed to “delusional symptoms in the context of relationship with an individual with prominent delusions” to clarify that (a) the “inducer” does not need to have a romantic relationship with the patient and (b) the “inducer” does not necessarily need to have a delusional disorder.
  • For persistent depressive disorder, the parenthetical “dysthymia” was removed to avoid confusion with DSM-IV-TR diagnosis of dysthymic disorder, which could not be diagnosed if the individual had ever met criteria for a major depressive disorder. Additionally, all specifiers were removed except anxious distress and atypical features.
  • The parenthetical “social phobia” in social anxiety disorder was removed.
  • For substance/medication-induced bipolar and related disorder, the DSM-5 Criterion A terminology “prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by elevated, expansive, or irritable mood, with or without depressed mood” was changed to “prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by abnormally elevated, expansive, or irritable mood and abnormally increased activity or energy.” Additionally, the DSM-5 Criterion B1 phrase “developed during or soon after substance intoxication or withdrawal or after exposure to a medication” was changed to “developed during or soon after substance intoxication or withdrawal or after exposure to or withdrawal from a medication.”

What changes were made to Section III in DSM-5-TR?

Section III of the DSM-5-TR contains emerging measures and models relevant to the diagnosis and conceptualization of mental disorders. Specifically, it contains several free assessment measures that counselors can use in clinical practice, additional information on cultural considerations for diagnosis, an alternative model for personality disorders, and conditions that are being considered for adoption in future revisions of the DSM. Changes made to Section III include the following:

  • Male and female checkboxes were removed from all assessment measures in a shift away from binary gender identification.
  • Instructions in the Clinician-Rated Dimensions of Psychosis Symptom Severity measure were edited to mirror new severity specifiers for psychotic disorders added to Section II.
  • Scoring instructions for the World Health Organization Disability Assessment Schedule 2.0 were clarified.
  • Terms such as “culture,” “race” and “ethnicity” were revised in the Cultural Formulation Interview. 

If I already own the DSM-5, do I need to purchase the DSM-5-TR?

Given that the DSM-5-TR contains a new diagnosis and updated research, I recommend obtaining a new copy. However, if you are not concerned with prolonged grief disorder and you do not use the statistical information in the DSM, then you may not have a sense of urgency to purchase the new edition.

Where can I go to learn more?

Here are some resources where you can learn more about the DSM-5-TR:

 

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Aaron L. NortonAaron L. Norton is the executive director of the National Board of Forensic Evaluators, a visiting instructor at the University of South Florida’s Department of Mental Health Law & Policy, and the southern regional director for the American Mental Health Counselors Association.

 

 

 

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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 Connoisseur: Fostering female mentorship in counseling

By Cheryl Fisher August 31, 2022

My cell phone lights up with a text from my 15-year-old client. He is mad at his parents who are constantly arguing and often use him as a pawn, and he has skipped school to make a point. He took his bike and rode to a local convenience store. His text says, “I will show them!”

In the process of calling my client, I get another call: It is his father. The call goes to voicemail, and he leaves a message saying that he is worried because his son left a note that he is running away. He has called the police and wonders if I have heard from his son.

I am torn. I want to maintain the trust of my client, but I also recognize that he is a minor and could be putting himself in harm’s way. His parents are extremely dysfunctional and are no doubt blaming each other for their son’s disappearance.

I take a deep breath and then pull up the phone numbers of three women who have served as my professors, clinical supervisors and now dear friends. I text, “I need a consult now. Are you available?” Within seconds my phone lights up again. When I answer, I hear the calm voice of one of my mentors. I summarize the situation and my concerns. She reiterates that my client is a minor and regardless of how dysfunctional the estranged parents are, they need to know the location of their son. After processing with her, I decide to call the father and provide him with the son’s location. I also point out for the 100th time that he and his ex-wife need to seek counseling to better navigate co-parenting because the current situation is too stressful for their son. The father thanks me and hangs up.

I immediately call my client to let him know that his father is on his way to find him and to give the client space to diffuse from the morning’s event. I apologize for the breach of his confidence and remind him that as a minor he could be in harm’s way by running off. I validate his frustration. And I ask for his forgiveness. He pauses a moment and then says, “Yeah, I figured you’d have to tell my parents. I am mad … but not at you. We’re good!” Then he sees his dad’s car pull into the parking lot and says, “I guess I’ll see you in session.”

I let out the breath that I felt like I had had been holding since my client’s initial text and call my mentor to thank her for the consultation and support.

The benefits of mentorship

Mentorship is when a more experienced person provides guidance to a less experienced person. The relationship may be formal (e.g., programs for emerging leaders) or informal (e.g., naturally occurring relationships that may develop between student and faculty). In a 2011 article published in Counselor Education and Supervision, L. DiAnne Borders and colleagues found informal mentoring relationships to be more “visible, meaningful, comfortable, individualized, effective, and long-lasting.”

Stephanie Maccombs and Christine Bhat, in 2020 article published in the Journal of Counselor Leadership and Advocacy, identified two areas where mentorship relationships can be most impactful: career development and psychosocial development. In addition to providing a way for the mentee to make connections in the industry, research consistently finds that engaging in a mentoring relationship is associated with positive outcomes for both mentor and mentee. For example, people who receive mentoring are more likely to experience career satisfaction and advancement. Additionally, students in mentoring relationships are more likely to complete dissertations and take advantage of professional leadership and research opportunities. This is especially true for female students.

Women in counselor education

Currently, there is not much data on women’s leadership in higher education. Ashley Gray, a senior analyst for the American Council on Education (ACE), studies leadership patterns in higher education and recommends that a deeper dive into the intersectionality of identities and experiences are needed to inform policy and practice of higher education (see Gray’s article in the 2021 edition of ACE’s International Briefs for Higher Education Leaders).

Although there are more women enrolled in higher education and appointed to junior faculty roles, too few female leaders exist in counselor education. Female leadership styles have historically been found to emphasize collaboration and teamwork which tend to promote innovation, and we need more innovative and transformative leadership to help navigate the existing challenges resulting from the COVID-19 pandemic.

Vectorium/Shutterstock.com

Systemic barriers

Women in higher education must often navigate competing efforts. These include balancing family and work responsibilities, navigating pregnancy and childbirth with the tenure time frame, and establishing relational networks that may be diminished by a patriarchal social structure. The pandemic further highlighted and exacerbated gender inequities: The increase in virtual learning brought the classroom into the home and caused women in higher education to navigate remote work and child care.

In their article “Only second-class tickets for women in the COVID-19 race. A study on manuscript submissions and reviews” (published in PLoS ONE in 2021), Flaminio Squazzoni and colleagues used the term “she-cession” to describe the disproportionate gender disadvantages created by the pandemic. Women submitted fewer manuscripts, participated in less research and applied for fewer research grants during the pandemic. However, there appeared to be an opposite impact on men in higher education, with more men publishing academic works during the pandemic.

Challon Casto and colleagues noted in their 2005 article published in the Journal of Counseling & Development that female counselor educators often lack the inside knowledge of internal structures and politics across department and university structures. This places women at a disadvantage in traditional “good old boy” systems that thrive on strong networks. The authors recommended creating a formal and informal system that connects female graduate students and marginalized students with mentors to help navigate the unspoken rules of graduate school and advancement.

Women’s Inclusion Mentorship Framework

Maccombs and Bhat created the Women’s Inclusion Mentorship Framework (WIMF), a model of mentorship specifically for women in counselor education programs. The WIMF provides mentorship opportunities and leadership development to any interested female student or faculty member. Based on their extensive review of research of higher education and mentorship in counselor education, Maccombs and Bhat identified four areas emphasized in the WIMF approach: (a) a relational-cultural focus, (b) quality mentors and mentor-mentee matches, (c) vision and plan development and (d) mentoring interventions specific to counseling and women.

A relational-cultural focus

Research consistently finds that mentorship relationships in counselor education contribute to psychosocial and clinical growth and, as noted by Maccombs and Bhat, to “a sense of empowerment, increased insight, increased self-efficacy” that results in mutual respect and empathy. Therefore, Maccombs and Bhat recommend that mentorship relationships are fostered between mentor and mentees who self-identify as women. Women mentors emphasize nurturing the relationship and encourage interconnectedness and the sharing of empowerment and authenticity. Interventions in line with this approach include self-reflection, self-care, connection to groups (such as in group writing) and recognition of the collective accomplishments of other women in the academic community.

Quality mentors and mentor-mentee matches

Quality mentorship can be challenging. Faculty are inundated with responsibilities and even the most well-intended mentor may fall short if they do not have the time to commit to the relationship. Additionally, incompatible pairing can be frustrating to both mentor and mentee. Mentors need ongoing training and support to be effective and sustainable. Maccombs and Bhat suggest that female mentors actively recruit other women in counselor education programs to a meet-and-greet event at the beginning of the academic year. This approach allows for an informal connection to occur organically between mentor and mentee, as mentors and mentees exchange information regarding research interests and academic and leadership experiences. And it also reduces the chances of incompatible pairing.

Vision and plan development

Maccombs and Bhat also recommend that that counselors outline the expectations of the mentorship relationship. Research indicates that clear expectations are associated with a more effective and satisfying mentorship experience. Additionally, mentees are encouraged to identify clear indicators of their academic and career vision. These could include increasing industry networking or scholarships such as publications or conference presentations. In addition to performance indicators, leader attributes and behaviors can be explored in a more measurable approach by using Chi Sigma Iota’s Principles and Practices of Leadership Excellence or the Dynamic Leadership in Counseling Scale — Self- Report (developed by W. Bradley McKibben and colleagues).

Mentoring interventions specific to counseling and women

Maccombs and Bhat encourage counselor education departments to consider allowing two to four hours of dedicated mentoring time a month. A flexible meeting schedule that works best for the mentor and mentee will be more successful. Additionally, a family-friendly approach that allows for child-care options or virtual meetings will be supportive of female mentees and mentors who may be caregivers. Service, research and teaching success include learning how to navigate these demands and other obligations. During pre-enrollment interviews, I encourage student applicants to approach their graduate degree as a “family degree” by recruiting the support of their partners, friends and family members in a variety of ways, including outsourcing some tasks and setting healthy boundaries. For example, family members can help with setting timers for lunch breaks on the weekend when the graduate student is immersed in research and writing papers.

According to Maccombs and Bhat, additional strategies around research and service include “being persistent, … avoiding personalizing the barriers, staying true to one’s personal plan or vision, and engaging in self-care.” It also helps if you are surrounded by a support system who can cheer you on during challenging times, such as dissertation editing.

Focusing on service activities that align with your areas of expertise or personal interests can create an extension of your personal worldview. My research interest in nature therapy, for example, has led me to be more engaged in sustainable ways and serve as the Green Office Ambassador for my counseling program. In this role, I helped the department identify ways to be more responsible with resources and sustainable in practices.

Finally, creating an environment of collaboration will aid in accessing the resources and knowledge to be successful in scholarship, teaching and service. Recently, I identified an area for growth at my university around research support for online faculty, who are mostly women in my department. I met with executive leadership and discussed my observations and suggestions. This resulted in plans to form a student and faculty clearinghouse for resources (e.g., research projects, grant opportunities) and a forum for trainings and mentorship on research development, implementation and publication.

Conclusion

Research indicates that mentorship relationships promote growth and satisfaction, professionally and personally. Women are often disadvantaged by historical academic and professional structures. But the WIMF provides one approach to capitalize on the mentorship relationship between women.

I have been fortunate in my career because I have always been surrounded by wise and empowered women. Women who dared to offer their secrets of success and wisdom in mentorship. They have shaped me professionally, informed me clinically and ultimately transformed me personally.

Whether it was providing me with feedback to hone my clinical skills, observing and ever so gently illuminating countertransference observed in a session, or simply bearing witness to my struggles of navigating work, family and graduate school, these women crafted a web of support as well as strategy that continues to sustain me as a clinician, counselor educator and administrator of a counselor education program.

I am forever grateful to the wise women who not only taught me how to be a strong clinical counselor but also guided me into my role as a counselor educator so that I may also mentor women entering the field of counseling.

 

In appreciation to my mentors, Sharon Cheston, Gerry Fialkowski and Rev. Anne Stewart.

 

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Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and associate professor for Alliant International University California School of Professional Psychology’s online master’s in clinical counseling. Her research interests include examining sexuality and spirituality in young women with advanced breast cancer, nature-informed therapy and geek therapy. Contact her at cyfisherphd@gmail.com.

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

Compromising care: An occupational hazard for counseling leaders

By Lindsay Johnson and Ane Turner Johnson August 10, 2022

When we sought to interview women directors of counseling centers about their experiences, we weren’t exactly sure what we’d discover. All we knew was that we were interested in their unique leadership experience given the conflicting values between care work and higher education today.

Higher education is not that different from many other large organizations. According to Bernie Grummell and colleagues’ article published in the journal Gender and Education in 2009, institutions are influenced by capitalism and therefore are more focused on the bottom line and on employees working solely for the benefit of the organization (even if it is to the detriment of their personal lives), resulting in what is considered to be a “care-less” organization. In a 2010 article for Arts and Humanities in Higher Education, Kathleen Lynch notes that this care-lessness manifests in leaders and workers becoming cutthroat, ruthless and selfish in order to excel within the organization.

As women working in a university setting for, cumulatively, over 20 years, we have become well attuned to the differing values between care divisions and the larger institution. And we have noticed that trying to lead divisions centered on providing care, such as a counseling center, within this care-less organization of higher education is fraught with tensions and contradictions.

Additionally, gender inequities inherent to higher education produces a gendered organization with its own set of challenges. As theorized by Joan Acker, gendered organizations create and maintain overt and covert practices, cultural dynamics and social norms based on gender that hinder women, especially their movement into leadership positions. Understanding how women directors navigate leading a care work division while also negotiating their role as a “care-less leader” within a gendered organization is essential to uncovering the interaction between gender, leadership and care work within the care-less landscape of higher education.

Photographee.eu/Shutterstock.com

Our curiosity in this topic spurred us to interview 13 women directors of college and university counseling centers from across the country. We wanted to know what it was like for them as leaders and how they experienced their dichotomous work environment. Using heuristic inquiry, we uncovered a culture clash between contemporary higher education and counseling that further marginalizes women leaders, particularly leaders of care work, by forcing them to compromise their care values and identities. These compromises are inevitable; to embody the role of a leader within the care-less organization of higher education, counseling leaders need to trade off some of their care roles, values and practices for those of the care-less culture. Without these compromises, counseling leaders risk their leadership status and effectiveness in the organization.

You may be reading this and thinking, “Yikes, this seems pretty bleak as a leader in the counseling profession.” Although that was our initial reaction, it also spurred us to consider how this knowledge could be useful. To us, these insights help professional counselors and counseling leaders within care-less settings prepare themselves for the internal (and sometimes external) assault on their values and identities. Also, this knowledge can help start a larger conversation within and outside the counseling field about care-less organizations and how care-lessness influences care work. In the following sections, we describe three ways in which the directors expressed they had to compromise care as a leader within a care-less context and three takeaways for counseling leaders.

Compromising care 

As mentioned previously, care-less work is born from our capitalist society that focuses mainly on profits and productivity rather than emotional connection. Bernie Grummell and colleagues in a 2009 article in Gender and Education and Henry Giroux in 2002 article in Harvard Educational Review explain that care-less organizations reward, value and idealize workers who can fully commit themselves to the job, put aside personal time and be unencumbered by any other type of duty. According to Sheila Slaughter and Larry Leslie in a 2001 article in Organization, higher education has become one such care-less organization, and therefore the presumption is that university faculty and staff, especially the leaders, will embody this ideal care-less worker. But these care-less values are in direct contrast to those of a division focused on care, such as a counseling center. As a result, leaders in these divisions must at times reprioritize their care to better align with the care-less institution. From our interviews, we found that counseling leaders often have to compromise care in the following three areas: care identities, leadership styles and practices, and care values.

1) Compromising care identities. The counseling leaders we interviewed said that compromises to care arose from the competing needs and values of their identities as a director, woman (for some this also included being a mother) and care worker (as professionals in the counseling field). As a result, they were forced to make sacrifices in their care roles given that it was impossible to effectively perform such roles while being the director of a counseling center. For example, one woman shared about her identity as a mother and how the director position affected the time spent with her children. She explained, “I get a call two weeks ago to do a suicide assessment with my kid in the bathtub, and I’m like, ‘I have to call you back, I have my kid in the tub,’ so I need to get my kid to my husband to be able to call back.” Another director echoed similar sentiments in regard to time spent with her father: “The hardest thing is I’ve been on call for so many years. … I can’t just go home and spend time with my father uninterrupted. … It can be a serious lifestyle inhibitor.” 

These examples exemplify the ways in which the care-less culture of higher education, and subsequent expectations of its leaders, infiltrate the personal lives of counseling leaders. The care-less culture contrasts with their care role as mothers and family caregivers and at times it was impossible to effectively perform both roles at the same time. Making personal sacrifices in their external care roles could risk their status as leaders within a care-less organization.

Counselors will also need to make professional care compromises when leading in a care-less organization. All the directors we spoke to still maintained involvement in clinical work; however, it was significantly minimized in order to manage their administrative position. One director with many years in her role explained why holding both identities (as care worker and leader) concurrently was nearly impossible. She said, “I started my role as director with a large caseload, but then I was trying to figure out how to be director and I was mediocre at both things — mediocre in the therapy room, mediocre as a director. … I can’t be doing good therapy and be thinking, ‘I forgot to approve someone’s vacation time.’ … I learned that I really needed to be more of an administrator.”

It’s challenging enough to sustain the engagement level involved in doing care work while also juggling administrative duties and expectations. Now add to that the complications that arise when working in an environment where the values of the care-less organization clash with the values of the care work being done. Therefore, being an effective administrator requires counseling leaders to make compromises to their care worker identity in some way.

2) Compromising leadership styles and practices. Another area where counseling leaders will most likely have to make compromises is in their leadership styles and practices. The directors we interviewed expressed that their leadership style is servant or feminist based, both of which are driven by care-oriented values such as collaboration, transparency and support. But at times they had to compromise those values and adapt a style that was more authoritative, political and guarded to navigate the murky waters of the greater care-less organization. One director explained why these changes needed to happen in her position: “I’m more guarded outside our office, in part because … I think there’s competition among departments. … There’s a bit of gamesmanship, so I need to be more strategic.” This statement reflects how our values as counseling leaders are compromised at times in a care-less organization to effectively do the job, such as obtaining appropriate resources.

3) Compromising care values. Counseling leaders may also have to make compromises to their care values in care-less settings. These compromises come as a result of the care-less cultural norms inherent to care-less environments. For example, students and their guardians may make demands of the university that are not necessarily in the best interest of the student’s mental health. But because the student (and whomever is financially supporting their college endeavors) are the “consumer,” the university is likely to appease these individuals. Middle managers of the institution, such as counseling center directors, are then subjected to following these decisions made by university leadership, without regard to care values. These compromises can range from keeping a student at the university when it may not be in their best interest to shrinking individual services or expanding group treatment in order to treat more students. Therefore, counseling leaders are forced to let the consumer dictate what is the care plan versus what they, as professionals, know would be most beneficial.

Lessons for caring care-lessly 

Learning how care-less contexts affect care leaders helps demonstrate the conflicts and unique challenges that arise for counseling leaders within higher education. These findings from our interviews with directors of counseling centers provides three important takeaways for other professional counselors who are already leading or will be leading counseling centers within care-less settings.

Lesson 1: Expect to feel conflicted. It was evident from our interviews with these directors that counseling leaders should expect to feel conflicted regularly when working in care-less settings. That is because care work leaders must reconcile their personal, and perhaps divisional/departmental, roles and values with those of the organization when they are in direct conflict to those of the organization. Research such as Simon Black’s 2015 article in Open Journal of Leadership supports this finding that care work leaders in care-less settings have internal conflict because of contradictory values. These leaders should also expect to feel conflicted because sometimes they will need to make sacrifices that come at the expense of their care identities. While counseling leaders may expect, and prepare for, ethical or legal challenges in their positions, the clash of personal and professional values may be less expected. By understanding this before entering the field, counseling leaders can reflect upon these compromises and prepare by doing things such as creating a plan as to when and how they may want to make such sacrifices.

Lesson 2: Expect to become flexible. As noted previously, we discovered that counseling leaders in care-less contexts often had to alter their leadership style when navigating spaces outside of their care division. Therefore, counseling leaders should expect to be flexible in their leadership approaches if they are going to get their care divisional needs met in a care-less organization. Although servant leadership can help individuals manage very challenging work obligations, as explained by Emin Babakus and colleagues in a 2010 article in Services Marketing Quarterly, it has been shown to be less effective in organizations that have more masculine-oriented values, such as care-less organizations, as described by the findings of Yucheng Zhang and others in an article published in Asia Pacific Journal of Management in 2021. When counselors in higher education lead a care division within a care-less organization, they must be ready to shift leadership styles based on what’s needed in the moment. Therefore, counseling leaders should be knowledgeable of multiple leadership styles, recognize when it is best to use practices associated with each style and be prepared to apply these different techniques. 

Lesson 3: Expect to be held accountable. The last takeaway for counseling leaders in care-less contexts is that compromising care can come at the expense of client’s or patient’s well-being and the care leader is most likely going to be held accountable. To us, this compromise is the hardest to stomach, and greatest call to action, as a care worker. We described earlier in this article how care-less organizational leaders may at times make decisions that affect care divisions and go against the values and professional judgment of counseling leaders. As a result, the clients or patients may suffer and view the care division as the culprit, and the organization is not likely to take the blame given its care-less values. This sabotages the leadership of care leaders. Counseling leaders should be aware of this when entering into care-less contexts and have a plan for how to manage conversations with leadership when such issues arise. This grim reality should also initiate conversations and more research around care-less cultures, including how they impact quality care and who accepts responsibility for such compromises to care.

In summary, it is important for professional counselors to understand that it is impossible for them to embody the values of their care worker identity while simultaneously working as a leader within a care-less organization. The inability to maintain both identities concurrently results in compromises made to one in order to embody the other. Therefore, counseling leaders in care-less settings should understand that compromises to their care identity must come in order for them to maintain their leadership role. As counseling leaders, this brings us to a crossroads. As we continue to expand our leadership into other industries, especially those that are care-less organizations, we must choose a path. We can either prepare ourselves to compromise our values and identities to fit into the care-less culture, or we can choose to confront the culture of care-less organizations. The latter choice raises several questions: Can care workers truly change the culture of a care-less organization? Do the care-less leaders need to be the ones to start a culture shift? Could counseling leaders be the catalyst for care-less culture changes? There’s only one way for us to find out.

 

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Lindsay Johnson is a licensed professional counselor and outreach coordinator at Rowan University’s Counseling and Psychological Services in Glassboro, New Jersey. She specializes in the treatment of disorders of over-control and is the team leader for the Radically Open Dialectical Behavior Therapy consultation team at Rowan’s Wellness Center. She recently completed her doctorate in educational leadership at Rowan University. Contact her at johnsonln@rowan.edu.

Ane Turner Johnson is a professor of educational leadership at Rowan University in Glassboro, New Jersey. She teaches research methods and conducts research on issues related to higher education governance and policy making.

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

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

5 tips to generate more leads from a therapist directory listing

By Wesley Murph July 20, 2022

Last October, I landed an exciting internship at a private practice. I just needed to see 12 clients a week to be able to graduate from a counseling master’s program the following March.

“That shouldn’t be a problem,” my supervisor said. “I’ll pay for your therapist listing. You should hit your goal in about a month.”

I wrote a profile of my clinical services for my therapist listing that I foolishly fell in love with. I submitted it to the directory and smiled when it was posted online. I’m about to get a boatload of leads, I naively thought, once everyone reads my amazing ad. 

Only that never happened.

The first week I received a fair number of leads, but many of these well-intentioned folks needed a therapist with more skills than I had.

The leads dried up with each passing week. At the one-month mark, I was seeing eight clients a week. Not nearly enough to graduate on time. So I began tinkering with my directory listing to see if I could get it to generate a predictable and steady flow of leads. This turned out to be a wonderful exercise because I discovered five ways to get more leads from my listing.

Julia Lazebnaya/Shutterstock.com

1) Rotate your zip codes

Some therapist directories let you target more than one zip code. One of your zip codes has to be your practice’s location — let’s call this your static zip code. The other two zip codes — let’s call them your flexible zip codes — can be anywhere in the state(s) you are licensed in.

I frequently target flexible zip codes that are outside of Portland, Oregon, where I work, because Portland is crowded with counselors. This has helped me generate more leads while serving areas in Oregon that may have a shortage of therapists.

I also recommend rotating your flexible zip codes, which is something I do every week. Think of this like fishing. If you fish in the same spot day in and day out, you are probably going to run out of fish to catch. This is especially true if other fishermen are fishing in the same spot. Rotating your flexible zip codes, however, lets you move your fishing pole (i.e., your counseling directory profile) so you’re fishing in areas that are restocked with fish (i.e., clients).

2) Track your listing

The online therapist directory I use provides the following metrics: total leads, calls, emails, website visits and profile shares. But it does not reveal how many leads became clients. Knowing this information is important because it helps determine which zip codes have a higher conversion percentage (i.e., leads that become clients).

And if the leads you generate are not booking appointments, you may need to tweak your approach. Are the demographics in this zip code a mismatch for you? Do you need to respond differently to your leads when you follow up with them? Or are there other reasons?

Another option is to find zip codes that have better conversion rates. To get this information, you can track your listing on a spreadsheet. (Google Sheets works great and is free.)

My tracking spreadsheet, which I named “Lead Tracker,” contains the following headings: listing platform, zip code, county, city, population, test date (the beginning and end date of the test), days of test (the total number of days tested), leads start, leads end, total leads, new clients and conversion rate.

I put the two flexible zip codes I’m testing underneath the “zip code” heading. I then calculate how many leads I generated during the test period (usually a week) using the metrics from the directory listing.

Let’s say I test the number of leads between July 1 and July 7. The leads start is the number of leads my directory service says I have on the day I start my test. So, using this example, if the directory service says I have 203 leads on July 1, then my leads start is 203.

The leads end refers to the number of leads my directory service says I have when I stop my test. If I stop my test on July 7 and my directory service says I have 213 leads, then my leads end would be 213.

For the total leads, I would subtract the leads start (i.e., 203) from the leads end (i.e., 213) to get the total leads (i.e., 10).

Next, I determine how many of those leads became clients by comparing the zip codes on my new client form to the zip codes I’m testing. (This is not error free since I also get leads from zip codes outside of the areas I’m targeting.)

I then calculate the conversion rate by dividing the number of new clients I got during the test period by the number of leads I generated. This percentage lets me know if the zip codes I’m testing are generating paying clients.

I sometimes target zip codes that have a high population density because there are more fish in these ponds. I’ll also target zip codes that have lower population density because there may be fewer fishermen fishing in these ponds. And since I accept Medicaid insurance, I target zip codes that align with the socioeconomic populations I want to serve.

You can find demographics about zip codes at zip-codes.com.

3) Include keywords in your listing

Another way to generate more leads from your online therapist directory is to include words and mental health issues that potential clients are searching for — but only add issues that you can competently treat and not just ones that are popular.

In a YouTube video, Jeff Gunther, the owner of online search platforms Therapy Den and Portland Therapy Center, notes that people most often search for the following three terms: anxiety, relationship issues and depression.

According to Gunther, anxiety is searched 14.3% of the time, relationship issues are searched 13.9%, and depression is searched 12.9%. So if you are clinically able to help clients who struggle with one of these issues, it makes good business sense to include these terms in your profile and specialties sections.

But don’t worry if you don’t specialize in one of these three areas. Gunther describes a few other mental health issues that are often searched: child or adolescent issues (4.6%), posttraumatic stress disorder (4.3%), LGBTQ+ issues (4.2%), self-esteem (3.6%), gender identity (2.7%), family conflict (2.4%) and loss or grief (2.4%).

4) Create a professional website

A website is a modern-day business card. Unfortunately, prospects will judge our clinical skills based on whether we have a website and how it looks. If you want prospects to see you as a professional, and ultimately choose you for counseling services, then it’s a good idea to spend some time (and money) on creating a sharp-looking website by having a professional website builder create your site and getting professional photos.

I invested $250 to have a photographer take and airbrush (thank goodness!) my picture for my website. I also invested $500 to have a professional build my website using Wix, a platform for creating websites that makes it easy to revise or tweak your site after it’s built.

I found both the photographer and website builder by placing a $5 ad on Craigslist.

A word of advice: Get quotes from several different website builders. The quotes I received varied in price depending on where the builder lived. The price quotes increased when the builder lived in an expensive city and vice versa.

5) Follow up with every lead

When it comes to responding to leads, I recommend following the golden rule: Treat people the way you want to be treated. I appreciate when the companies I reach out to for services take the time to respond to me, and I want to be this type of business owner too. (It’s also good karma!) So I respond to every lead who reaches out to me — even if my schedule is full.

People often tell me I am the only counselor who follows up with them. I am not sharing this to shake my own rattle. But when the pond I’m fishing in is teeming with other counselors, I want to be the counselor who stands out because this ensures that people will remember (and hopefully refer) me. And if it works for me, it can work for you too.

 

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Wesley Murph is a professional counselor associate and a national certified counselor who is working toward full licensure in Oregon. Before earning a master’s in clinical mental health counseling, he owned two small businesses, including one that was featured on Dog Whisperer with Cesar Millan. His joy is being with his young son and wife. You can find him at BuildingBetterOregonians.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.

Rethinking the accessibility of digital mental health

By Chris Gamble July 11, 2022

If your social media algorithm is anything like mine, you’ve probably seen an increasing number of ads for companies offering teletherapy through an app-based platform. Maybe you’ve seen Olympians Michael Phelps and Simone Biles sharing their own mental health stories in TV commercials for a couple of these companies. Regardless of how you come across your information, one thing is clear: the digital mental health (DMH) era is here. 

A 2020 report by the World Innovation Summit for Health defined DMH as “the use of internet-connected devices and software for the promotion, prevention, assessment, treatment and management of mental health, either as stand-alone tools or integrated with traditional services.” This can include platforms that offer varying combinations of therapy, medication management and coaching and those that don’t provide therapy but instead rely more on self-guided, therapist-created content. There are even artificial intelligence chatbots and virtual reality-based mental health interventions, which are likely to expand with the buzz surrounding the metaverse (a digital world where people can interact with others in a computer-generated environment). Throw in meditation apps, guided journals and mood trackers and the crowded bucket of DMH is surely overflowing. 

Although many of these platforms existed before 2020, the onset of the COVID-19 pandemic contributed to their expansion, as many poised themselves as solutions for filling the access gap made wider by the global health crisis.

I have worked as a licensed professional counselor in Washington, D.C., for six years, mostly with low-income, Black youth and families in schools, community-based agencies and currently a children’s advocacy center. So, the constraints of a fragmented public mental health system, long waitlists and a lack of culturally relevant services have been at the forefront of my mind for quite some time now. I regularly see how inadequate availability of quality mental health services can compound trauma and further complicate the healing process. As a Black counselor, I am protective of the populations I serve and vigilant toward any sweeping claims of answers to long-standing problems. Thus, I keep my clients and other marginalized groups in mind when approaching the larger question of how access can be improved through the medium of digital technology. In this article, my aim is not to endorse or dissuade from any specific DMH company but to examine the field of DMH and its shortcomings in improving access for marginalized populations.

Accessible for whom?

In the public discourse around mental health, access is often limited to definitions of ease and convenience. People often assume that removing the burden of internet searches and transportation needs and increasing privacy protection by being in one’s home are key to making mental health care more accessible. In this sense, app-based therapy seems to be a good fit. At least for some. 

The COVID-19 pandemic and the need for schools to switch to remote learning exposed the digital divide in the United States. I personally witnessed similar issues in my community mental health work at the time. For many low-income, Black households, a parent’s smartphone may be the only internet-accessible device they have, or their internet service may not be adequate to sustain full therapy sessions. Add to that the higher likelihood of multigenerational households within certain racial groups, and suddenly one’s home is not so private. Even more barriers exist for disabled people and those with no or limited English proficiency. Considering the amount of work it takes to develop an app, it is concerning that these issues are so often overlooked. If the innovations spurred by DMH continue to ignore cultural differences and structural disparities, the contradictions with goals of increased access will only become more noticeable.

For apps offering self-guided content and therapist-created videos or live discussions, we have to wonder about the cultural relevance of this material. A quick look at popular media and creative content-based platforms supports the suspicion that certain groups could be catered to over others. This is an inherent vulnerability in the “attention economy.” In the battle for our eyes and ears between social media, podcasts, TV and movie streaming, music streaming, and video games, DMH platforms are poised to join the arena. Adding self-guided and therapist-produced content to attract users may seem antithetical to attending to their mental health needs, but when subscriptions and engagement drive a company’s value, what safeguards keep this from happening? 

Given these market-driven incentives, it is imperative that marginalized communities are able to find content that reflects their lived experiences. And DMH companies will need to demonstrate a responsibility to these communities and not stray from public accountability. Suppose a company signs a contract with a popular therapist with a large social media following to produce informational and educational videos for their app. Over time, perhaps users begin to notice cultural bias in this therapist’s mental health tips, or the therapist becomes the subject of a scandal involving discriminatory behavior or public commentary. Would users again be left to trust a tech company to make moral decisions over monetary ones? And how a company responds to such an issue could illustrate whether the well-being of marginalized groups is a priority. Counselors would be wise to take notice of this intersection between the mental health field and broader societal trends in order to understand the varying effects on different groups.

Impacts on the mental health workforce

DMH is also positioned as a solution to fill the gaps in the mental health workforce shortage by using technology to bring clinicians to underserved areas. Let’s first look at what might draw counselors to working for DMH companies. One potential benefit is that therapy apps could handle the business aspects of independent practice, such as insurance paneling, client referrals, scheduling and billing. Taking these responsibilities off the counselor’s plate can make the increased use of these platforms attractive to the field, especially for those who prefer working from home or other remote locations. 

Before looking at how this affects access, we can’t disregard possible downsides for DMH workers. Because many DMH companies are startups, they tend to rely on contract work to facilitate business growth. There have even been instances of changing salaried, benefit-receiving employees into contractors, leaving therapists in precarious financial positions. Other practices such as being paid per the number of words texted to clients call into question whether a counselor would be incentivized to provide care for clinical reasons or personal financial ones. Everyone’s finances and living conditions are different, but these parallels to the gig economy should draw caution. On a broader scale, accepting pay that doesn’t match the labor, along with following business practices that are possibly out of line with the ACA Code of Ethics, can influence how the counseling profession is perceived.

GaudiLab/Shutterstock.com

In the presence of a DMH industry looking for more workers, the previously mentioned problem of the digital divide becomes heightened. As more mental health professionals transition to DMH platforms, fewer are left to work with those who can’t access them. This trend could accelerate even further if we consider the recent progress with establishing the Counseling Compact. I and many others have been eagerly awaiting this development, but I also wonder: Could expanding our reach through the Counseling Compact amid increased DMH options end up siphoning the counseling workforce away from those most in need within our proximity? For instance, if I took advantage of licensure portability in the future and was able to practice in several different states, my caseload would likely be easier to fill and maintain, but marginalized D.C. residents would suddenly find my services to be less available. If licensure portability were implemented on a larger scale, counselors may cast a net so wide that those closest to them end up falling through the holes. 

What to do?

Now that the possible effects of DMH on marginalized groups and the counseling profession have been laid out, the question remains: What can we do about it? Here are some ideas to consider.

1) Get to know the research. With billions of dollars being invested into DMH, the industry does not seem to be going anywhere anytime soon. Counselors need to pay attention to the research and marketing around these products in order to understand what is being prioritized. Determining whether apps are equally or more effective than in-person therapy will be an ongoing project, with outcome-based studies being conducted both internally by DMH companies and by independent parties. It is important for counselors to know what constitutes a quality study design and how companies represent their evidence-based claims. Sample size, outcome measures and the time range of studies are all things to keep in mind. A glaring omission I’ve noticed within much of the DMH research is the lack of racially diverse participants and the fact that sometimes racial demographics are not collected at all. To position DMH as improving access without even looking into possible differential outcomes for people of various identities could actually result in deepening preexisting health inequities. I encourage counselors to take the time to browse the websites of different DMH companies to see if the research studies they reference collect comprehensive demographic data, and then ask themselves what this means in the context of who the app is marketed to.

2) Find the problem-solvers. There are growing pockets of research focused on these problems and their potential solutions. In a 2021 article published in JMIR Mental Health, Elsa Friis-Healy and colleagues developed five recommendations for how the DMH industry can design products that increase utility for racially and ethnically minoritized groups. There are also implementation studies such as Samantha Connolly and colleagues’ 2020 narrative review, published in the Journal of Technology in Behavioral Science, which examined factors for successful implementation of mental health apps, from their design to their uptake and sustained usage. Counselors can use research such as this to understand what elements make for a quality app, thereby empowering us to make informed decisions around their use. Additionally, we can get involved in developing ways to advocate for these solutions or propose our own, whether through national organizations already doing this work or by creating local networks attuned to local needs.

3) Know your clients. Most importantly, counselors who work with marginalized populations need to recognize all the ways their clients can be left behind by an increasingly tech-focused field. By leveraging what we know about the social contexts we work in, we can become better equipped to dismantle barriers to DMH or identify more appropriate solutions to access needs.

Conclusion

The necessary uptake of teletherapy onset by the pandemic lockdowns seemed to open a door to solving the long-recognized problems associated with accessing mental health services. If the heads of DMH companies are the main force behind this change, however, there may end up being more hurdles than expected. This article explores some of the mismatches between DMH’s promises and the needs of communities most affected by the inaccessibility of mental health services. By incorporating the conversation of technology and access into the counseling profession’s efforts to practice with cultural intentionality, we can ensure the best interests of all clients are maintained amid the rapid changes occurring in our society.

 

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Chris Gamble is a licensed professional counselor, national certified counselor and certified clinical mental health counselor based in Washington, D.C. He is committed to showcasing the power within marginalized communities. Contact him at cmgamble92@gmail.com and follow him on Instagram @chris_thecounselor.

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

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