Tag Archives: Professional Issues

Professional Issues

Healthy conversations to have

By Kathleen Smith July 26, 2017

In the United States, 1 in 6 adults has a prescription for a psychiatric drug. That ratio only increases among individuals who walk into counselors’ offices, leaving many counselors feeling that they must perform a special type of tightrope act to talk about medications with their clients. Given that licensed professional counselors don’t possess prescription privileges, some counselors feel that they lack the training to carry on such discussions. Other counselors fear letting their own beliefs and biases show. Regardless of the reason, some counselors are quick to refer clients back to their doctors or psychiatrists rather than engaging clients in a thorough conversation about medication management themselves.

Because primary care physicians write almost 70 percent of antidepressant prescriptions, counselors may find that new counseling clients who are on medication have yet to have an extended conversation about medication management and their overall mental health. These clients may not have given much consideration to how long they want to stay on medication, or they may be uninformed about the possible risk of growing dependent on sedatives, anxiolytics and other medications.

Several counselor educators are taking up the charge of encouraging more informed and comfortable conversations in the counseling room about client medications. American Counseling Association member Dixie Meyer presented with colleagues at the association’s 2016 conference in Montréal on adjunctive antidepressant pharmacotherapy in counseling. Meyer dedicated her dissertation research to the sexual side effects of antidepressants and their effects on romantic couples. As her research expanded, she grew more and more fascinated with exploring the relationship between psychopharmacology and counseling.

Today, as an associate professor in the Department of Family and Community Medicine at St. Louis University, Meyer educates many primary care physician residents, and she notes that counselors sometimes forget that they have a unique ability to conceptualize clients. “Primary care physicians are expected to be able to know pretty much anything, but they do not have the same level of depth in their mental health training,” she says. “Counselors need to really think about what kind of information they can share with a primary care physician, and the answer is, a lot.”

Meyer explains that counselors may have a greater understanding of the impetus for the client’s condition, the specific symptoms the client has experienced, which of a medication’s potential side effects might be more of a challenge for the client and what additional resources the client may need to maintain medication adherence.

Biases and fears

Professional counselors carry their own biases and values related to psychiatric medications, often based on their individual experiences and training. It is easy to see how the counseling profession as a whole might feel threatened by the statistics, however. For example, nearly $5 billion is spent every year on TV ads for prescription drugs. Then there is the fact that more than half of all outpatient mental health visits involve medication only and no psychotherapy.

A physician assistant with a second master’s degree in counseling, ACA member Deanna Bridge Najera is frequently invited to talk to counselors about improving dialogue between medication prescribers and counseling professionals. She gave a presentation at the ACA 2017 Conference in San Francisco titled, “Medicine Is From Mars and Counseling Is From Venus: How to Make It Work for Everyone.”

Najera has heard skeptical counselors make many statements about psychopharmacology, including that such medications turn people into “zombies,” alter their personalities or simply produce placebo responses. As a master’s counseling student, she also heard many comments from fellow students about their negative relationship with medication or their family members’ negative experiences.

“We have to make sure that we have these conversations out loud,” Najera says. “We have to ask counselors what their concerns are. The way I explain it, the medicine is supposed to allow you to be who you’re supposed to be. It doesn’t change who you are; it just makes it more manageable to learn and grow.”

Although there is still no clear winner in the medication versus therapy debate, researchers are learning more about who might respond to one treatment better than the other. For example, a 2013 study in JAMA Psychiatry found that patients with major depression with low activity in a part of the brain known as the anterior insula responded well to cognitive behavior therapy and poorly to Lexapro. Those patients with high activity in the same region did better with medication and poorly with the therapy. Researchers have also concluded that patients who are depressed and have a history of childhood trauma do better with combined therapy and medication than with either treatment alone.

“We chose our profession because we believe in our profession,” Meyer says, “but the research is going to report no differences between counseling and medication. I do see a lot of bias, and one of my concerns is that our No. 1 goal should be to help the client. So whatever the client’s perspective is, whatever the client thinks is going to help them is probably what will help. They are the experts on their own life.”

Erika Cameron, an associate professor of counseling at the University of San Diego and an ACA member, presented with Meyer in Montréal. When they were enrolled in the same doctoral program, Cameron found herself sharing Meyer’s interest in psychopharmacology and considering how she could respond to the general wariness of school counselors around the topic of medication.

“There can be a bias that that’s not part of their role. They are not diagnosing or prescribing, so they don’t need to know about medication,” says Cameron, who once worked as a school counselor. “But by not talking about it, we might be harming the client. Or if you don’t know that a student is on a medication, then you don’t know what behavior sitting in front of you is normal or atypical for that particular student.”

Another common trepidation among counselors is the fear of stepping outside their lane when it comes to talking about psychiatric medication. Clients often ask for advice about certain medications or when starting any type of drug, but there is a temptation among some counselors to avoid the subject or simply to refer all questions in that vein to a psychiatrist or doctor.

Franc Hudspeth, associate dean of the counseling program at Southern New Hampshire University and also a licensed pharmacist, says that counselors should serve as educators and advocates when it comes to client medications. “We should never cross that line of telling a client what to do with that medication,” he says. “We have to refer back to the foundation of our profession. We help individuals overcome problems, and we don’t give them the solutions. It’s saying to the client, ‘If you have concerns, we can present this to your prescribing physician, and I will support you in any way, but I’m not going to tell you how to do it or what to do with the medication.’ I wouldn’t even do that as a pharmacist. We have to help people make the best decisions based on the best information.”

Hudspeth also says that he observes more of a general hesitancy at work than a fear of liability among counselors. “If someone advocates for their client and their voice gets squashed by a physician or a psychiatrist, there may be some hesitancy to get involved. But it never hurts to voice concerns and to be the advocate for your client,” he says. “[Still], I do think that some counselors fear the repercussions of helping a client speak up.”

Having the conversation

How exactly should counselors respond when clients want to talk about psychiatric medications? In an effort to provide effective psychoeducation, Meyer says, counselors shouldn’t be shy about asking thorough questions upfront concerning clients’ beliefs and ideas related to medication. She suggests asking questions such as, “How do you know that you want to be on a medication?” and “Are you likely to have another depressive episode?” Questions such as these can provide valuable insight into the client’s knowledge (and knowledge deficits) about medication. For example, a client who wants to take an antidepressant might not realize that half of all individuals with depression will not experience another episode.Most frequently prescribed psychiatric medications in the U.S.

Najera also encourages counselors to ask clients where they obtained their knowledge about particular medications. “Many people have the idea that newer is always better, which study after study has shown is not true,” she says. “A client might see a commercial for a new medication and ask if it will work. I’d rather them not break the bank for a new medication when there’s a $4 medication at the local pharmacy that’s just as effective.”

Hudspeth suggests that counselors do a medication check-in with clients at every session. He says the best question counselors can ask clients who are already on medication is, “How is your medication treating you?” This kind of general question can help counselors gather information without overeducating clients in a way that predisposes them to having side effects, Hudspeth explains.

Cameron agrees that the simplest approach is often the most empowering for clients. “Sometimes [it’s simply] asking, ‘Did you read the really long paper that came in the bag with your pills? What is the medication really treating? What are its side effects? What would be considered not normal for you?’ [It’s] educating clients to be critical consumers of their medication,” she says.

Cameron also encourages counselors to role-play conversations that clients could have with their prescribing doctors. Counselors can assist their clients with compiling a list of questions to ask and also encourage them to track their symptoms, thoughts and feelings while on a particular medication. Data can be a powerful tool for holding doctors accountable for connecting clients with the best medication options, but sometimes clients need to learn what to observe while on their medications, Cameron says.

Counselors may also need to have conversations with clients about the impact that their physical health can have on their mental status. Meyer encourages counselors to take time to consider how nutrition, physical illnesses, medications and other substances could potentially influence the mental health of their clients. Anything from high blood pressure medication to birth control pills to low iron could be a culprit, and Meyer worries that individuals who don’t provide their doctors with detailed information about their health are at risk of being prescribed medications that don’t fit their particular symptoms.

“If a client has not had a physical in a long time, then you do not know if there are cardiovascular concerns, hormonal concerns, cancer symptoms or one of the many other disorders that can have depressive side effects or present as depression,” Meyer points out.

Counselors are also charged to have open and honest conversations with parents who are worried about putting their children on psychiatric medications. When Hudspeth worked as a pharmacist in the early 1990s, he began noticing that many children were being medicated without solid reasoning to back it up. Thinking there might be a better approach, he went back to school to become a counselor and later a counselor educator. In his counseling work with children, he has fielded many questions from parents about whether their child should be evaluated for the need to take psychiatric medication.

“My perspective is that the evaluation isn’t going to hurt anything,” Hudspeth says. “I tell parents that they don’t have to make the decision to choose medication, but if the child is medicated, he or she will also do better if they’re in therapy. The two treatments are synergistic, and our goal as a team is to find the [right] balance of different components.”

Cameron adds that school counselors are presented with the complex task of advocating for developing kids who are on medication. “Because there’s so much hormonal change and physical growth, medication may need to be adjusted more frequently,” she says. “School counselors have the ability to see these students on a daily basis, and if we’re not paying attention to these changes, there could be a downward spiral before something
is corrected.”

Psychopharmacology in counseling classrooms

Counselor educators are tasked with preparing their students for the increased use of psychiatric medication among their clients. The 2016 CACREP Standards require clinical mental health counseling students to be educated about the “classifications, indications and contraindications of commonly prescribed psychopharmacological medications for appropriate medical referral and consultation.” Similarly, the CACREP Standards say that counselor education programs with a specialty area in school counseling should cover “common medications that affect learning, behavior and mood in children and adolescents.”

Hudspeth is of the belief that every master’s program in counseling should require a psychopharmacology course. “When 50 percent of our clients are on medication, we should have a basic foundation for understanding psychopharmacology,” he says. “New practitioners need to be better prepared for what they’re going to face in internship or post-master’s work, so they should be familiar with what medications are used for what disorders and what kind of side effects pop up.”

A 2015 article in the Journal of Creativity in Mental Health by Cassandra A. Storlie and others explored the practice of infusing ethical considerations into a psychopharmacology course for future counselors. The authors argue that counselor educators should engage students in talking about how their own values and perceptions about medication use could potentially affect the quality of counseling service they provide. The authors tracked the success of one psychopharmacology course that asked students to complete a variety of creative assignments, including reporting on a legal or ethical issue in the field of psychopharmacology, interviewing an individual who takes a psychotropic medication and discussing fictional client scenarios. At the end of the course, students reported greater confidence in how they understood their role related to discussing medication with clients.

Cameron agrees with the benefits of offering a psychopharmacology course to counseling students. She also sees value in inserting medication conversations into her supervision work with students. When her students bring in case conceptualizations during their internship work, she asks them to list what medications the client is taking. She then asks them to educate their peers about what each medication is treating, what the dosage is and any typical side effects.

“I have to model being comfortable bringing up the topic of medication so that my students get more comfortable,” Cameron says. “Often they don’t talk about medication because they feel that they don’t know it all. They don’t want to give bad information. But they can learn to take a proactive role by sitting with a client and saying, ‘Hey, let’s look this up. Let me get this resource guide or a consult on this.’ There’s this fear, especially with student counselors, that you have to know everything to be able to be helpful.”

Areas for growth

Of course the work of medication education doesn’t end with graduate school. New medications are steadily being introduced, and over time researchers will learn more about the long-term effects of popular ones. Cameron recommends that counselors keep a copy of the Physicians’ Desk Reference, a compilation of information on prescription drugs, in their office. “They update it pretty regularly, so when you have clients come in, you can open the book and figure out what’s going on,” she says.

Hudspeth says counselors should stay informed but also avoid the subtle ways in which they might give advice about any medication, including over-the-counter ones. “A client may come in and say, ‘I’m having difficulty sleeping,’ and a counselor says, ‘Have you tried melatonin?’ They just stepped over that line,” Hudspeth says. “Just because you can buy it at Target or Walmart doesn’t mean you should be asking those questions.”

Meyer suggests that counselors who feel overwhelmed with the breadth of information on medications begin with the client population they serve most frequently. “What information can help your particular clients?” she asks. “Start there and seek out information, depending on who’s coming in and how you can treat them to the best of your ability.”

Above all, Meyer recommends that counselors never forget to take the topic of medication seriously in their work and training. “When you are choosing to take a medication, you may be choosing to have potential side effects. You are choosing that you will alter your neurochemistry. That is not a decision that should be taken lightly. It is not an easy decision,” she says. “When a client makes a choice about whether to take a medication, they need to make it from a place where they are well-informed.”

 

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

Letters to the editor: ct@counseling.org

 

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

ACA advocates for Medicare bill on Capitol Hill

By Bethany Bray July 20, 2017

ACA leaders gather for a day of advocacy on Capitol Hill on July 18. (Photo by Paul Sakuma)

A bill that would allow professional counselors to be reimbursed for the treatment of clients under Medicare has been introduced in the House of Representatives, and more than 100 counseling professionals added to its momentum by advocating in person on Capitol Hill earlier this week in an event organized by the American Counseling Association (ACA).

Currently, Medicare does not reimburse licensed professional counselors (LPCs) for the treatment they provide for older adults who carry this federal insurance coverage. However, ACA is advocating for a bill that would add LPCs to the list of providers who can be reimbursed under Medicare – a list that already includes clinical social workers and marriage and family therapists. H.R. 3032 was introduced last month by Rep. John Katko (R-N.Y.) in the House of Representatives, and a companion Senate bill is expected to be introduced shortly by Sen. John Barrasso (R-Wyo.) and co-sponsored by Sen. Debbie Stabenow (D-Mich.).

H.R. 3032 currently has three co-sponsors: Reps. Mike Thompson (D-Calif.), Elise Stefanik (R-N.Y.) and Zoe Lofgren (D-Calif.). If passed, the measure would add an estimated 165,000 mental health providers to the Medicare network, providing much-needed access to care for older adults in the United States.

On July 18, 125 ACA members from across the United States visited the Capitol Hill offices of their senators and House representatives to ask for support for the Medicare bill. The counselors were gathered in Washington, D.C., for ACA’s annual Institute for Leadership Training (ILT), a four-day conference of education sessions, trainings and business meetings for leaders in the counseling profession.

“In the United States, exercising our First Amendment rights under the Constitution is vitally important to ensure that we have a strong and responsive government,” said ACA Director of Government Affairs Art Terrazas. “I am so happy that we were able to help ACA leaders from across the country meet and speak with their federal lawmakers about the needs of the counseling profession.”

Amanda DeDiego, an ACA member from Casper, Wyoming, talks with Sen. John Barrasso (R-Wyo.) in his Capitol Hill office. (Photo by Bethany Bray)

Amanda DeDiego, an ACA member from Casper, Wyoming, met with Sen. Barrasso to thank him for his upcoming sponsorship of the Medicare bill. Barrasso expressed his support for the issue, saying “the needs are great” in Wyoming. For example, the average life expectancy on Native American reservations is 47 years – decades below that of Wyoming’s general population – and issues related to mental health are part of the cause, Barrasso said.

A delegation from the American Counseling Association of New York (ACA-NY) met with staff in the office of Sen. Kirsten Gillibrand (D-N.Y.) to ask for co-sponsorship of the bill that Barrasso soon will introduce in the Senate.

ACA-NY leaders Summer Reiner, Allison Parry-Gurak and Tiphanie Gonzalez (ACA-NY president) explained that LPCs have training and graduate coursework that is equal to or exceeding that of the social workers and other mental health practitioners currently covered under Medicare. In the rural parts of New York, a dearth of mental health providers already exists, and that number shrinks further for people who rely on Medicare coverage for treatment, Reiner explained.

“There’s a huge need,” said Reiner, an associate professor at the State University of New York (SUNY) in Brockport and ACA-NY past president. “There are more than enough clients to go around, and we all have a different perspective for a reason.”

“We’re very much cousins in the exact same family, with different specialties,” agreed Gonzalez, an assistant professor at SUNY Oswego.

ACA members who visited legislative offices on July 18 also advocated for full funding of the Title Four block grant as part of the Every Student Succeeds Act (ESSA). The grants, some of which goes to support school counseling programs, were funded at $400 million, or just 25 percent of the $1.6 billion that was authorized this year. President Trump’s proposed budget for 2018 recommends no funding for the block grant at all.

Terrazas, in a training session held prior to the Day on the Hill event, urged the assembled ACA leaders to follow up with their legislators, stay informed and continue pushing for issues that are vital to the counseling profession.

“Advocacy doesn’t start and end with just this day [on Capitol Hill] tomorrow; it is year-round,” said Terrazas.

 

ACA members from Louisiana speak with staff in the office of Congressman Steve Scalise (R-La.) on July 18. (Photo by Bethany Bray)

 

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By the numbers: ACA Day on the Hill 2017

125 ACA members from 37 states, plus the District of Columbia, U.S. Virgin Islands and Puerto Rico, visited 74 Senate offices and 95 House offices

ACA President Gerard Lawson also met with

  • James Paluskiewicz, staff, House Committee on Energy and Commerce
  • Nick Uehlecke, staff, House Committee on Ways and Means
  • Allison Steil, deputy chief of staff, U.S. House Speaker Paul Ryan (R-Wis.)
  • Wendell Primus, office of House Minority Leader Nancy Pelosi (D-Calif.)

 

Cynthia Goehring and Sarah Shortbull, ACA members from South Dakota, met with Sen. John Thune (R-S.D.) on July 18. (Photo by Paul Sakuma)

 

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ACA awards Murray, Lieu

ACA has recognized Rep. Ted Lieu (D-Calif.) and Sen. Patty Murray (D-Wash.) with an Illumination Award for their work against harmful conversion therapy. Lieu and Murray have introduced bills in the House and Senate, respectively, that would classify commercial conversion therapy and advertising that claims to change sexual orientation and gender identity as fraud.

An ACA delegation met Murray on July 18 to recognize her on Capitol Hill; Lieu was previously honored at last month’s Illuminate symposium, a three-day conference in Washington, D.C., focused on the intersection of counseling and lesbian, gay, bisexual, transgender, questioning or queer (LGBTQ) issues.

Sen. Patty Murray (center left, in grey suit) is given an ACA Illumination Award on July 18 by ACA Past President Catherine Roland, current ACA President Gerard Lawson and ACA President-elect Simone Lambert, along with ACA members from Washington state. (Photo by Paul Sakuma)

 

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To stay up-to-date on the Medicare bill and other current issues, sign up for updates from ACA Government Affairs at counseling.org/news/aca-blogs/aca-government-affairs-blog

 

Search for the hashtag #ACAILT2017 for social media posts from ILT and the Day on the Hill

 

See more photos on the ACA flickr page: flickr.com/photos/23682700@N04/albums/72157686345016025

 

A delegation from the American Counseling Association of New York (left to right) Tiphanie Gonzalez (ACA-NY president), Summer Reiner and Allison Parry-Gurak met with staff in the office of Sen. Kirsten Gillibrand (D-N.Y.) to ask for cosponsorship of the Medicare bill that Sen. Barrasso will soon introduce in the Senate. (Photo by Bethany Bray)

 

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

 

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

 

Counselors asked to advocate against FY2018 federal program cuts

By Bethany Bray June 13, 2017

The American Counseling Association will be keeping a sharp eye on federal budget proceedings through the next few months, as several programs critical to the work of counselors and school counselors are on the chopping block.

Counselors can – and should – make their voices heard throughout the process by advocating to their congressmen and congresswomen, reminding them of the critical work that counselors do, Art Terrazas, ACA’s director of government affairs, said during a recent ACA webinar on the federal government’s fiscal year 2018 budget.

The May 25 webinar gave an overview of the cuts pertinent to professional counselors in President Donald Trump’s proposed budget for FY2018. The proposed budget seeks to offset an additional $57 billion in military spending with cuts to domestic and federal programs, the majority of which are in the U.S. Departments of State, Education and Health and Human Services.

Of particular concern to the counseling profession is the proposed decimation of the Student Support Academic Enrichments (SSAE) grants program, which is the only federally funded program that directly supports school counselors. The president’s proposed budget would eliminate all funding for the program, a bipartisan-supported initiative that was previously authorized for $1.65 billion over the next four years.

As envisioned by Trump , the budget would also eliminate funding for the federal Child Health Insurance Program (CHIP) and the public service student loan forgiveness program, as well as reduce funding for Medicaid – all of which would affect professional counselors.

While Trump’s proposed budget is “pretty grave” for professional counselors, it’s also just a wish list that outlines the president’s priorities, said Chris Andresen, a public policy strategist who spoke at the webinar with his colleague Jayne Fitzgerald. Andresen and Fitzgerald are both senior vice presidents at Grayling, a public affairs firm ACA has partnered with for a number of years.

Ultimately, Congress must draft the actual FY2018 budget, explained Fitzgerald. This process will play out over the summer, as a budget is crafted and vetted via congressional committee hearings. A budget resolution will need to be passed by September 30 to keep the federal government funded and operating.

“We’re just going to have to see how all of this plays out. Right now, we don’t know,” Andresen said during the webinar. “With the changes that are being proposed there are going to be less tools in the toolbox for [counselor] practitioners such as yourselves and your clients in access to services. That gives us a lot of concern.”

The next few months will be a compressed, fraught process as Congress not only debates the budget but healthcare as well (a possible replacement for the Affordable Care Act), said Fitzgerald. At the time of the webinar, there were 43 legislative days left on the calendar.

“We’re on a ticking clock. September 30 will come quickly,” said Andresen.

 

 

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View the full webinar here: youtu.be/hz-d9L4ogZc

 

Email follow-up questions on this issue to mylearning@counseling.org

 

Contact your legislators via: counseling.org/government-affairs/actioncenter

 

Sign up to receive ACA Government Affairs news updates via email here: counseling.org/news/aca-blogs/aca-government-affairs-blog

 

 

 

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

 

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

 

 

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

ACA continues push forward for licensure portability

By the Counseling Today staff June 6, 2017

The American Counseling Association Governing Council has endorsed a plan that would allow counselor practitioners who are licensed and in good standing in one state to become seamlessly licensed in other states should they move.

The lack of licensure portability — being able to transfer a professional counseling license when a practitioner moves to a different state — has long been an issue within the profession and is frequently cited as one of the top frustrations of professional counselors. Counselor licensure titles and requirements vary from state to state across the U.S., sometimes forcing even the most veteran of counselors to obtain additional supervision hours or meet other requirements before securing a new license after moving across state lines.

The ACA Licensure Portability Model, passed by the Governing Council in June 2016 and reaffirmed this past March, calls for counselors who are licensed in one state and have no disciplinary record to become eligible for license “in any state or U.S. jurisdiction in which they are seeking residence.” The model allows that states may require these counselors to take a jurisprudence exam to verify that they are knowledgeable about the laws in that particular state.

To become a reality, the ACA Licensure Portability Model must first be adopted by individual state licensing boards across the U.S. The procedure for taking this action varies from state to state. Some licensing boards possess the ability to change regulations on their own, whereas others must first petition their respective state legislature.

“I was amazed to see the progress that last year’s Governing Council made and how this year’s board has been so supportive of our rolling out the model that was adopted,” comments ACA CEO Richard Yep. “We look forward to working with licensing boards across the country in order to ensure that qualified professional counselors have the ability to practice in the jurisdiction of their choice.”

During her year as ACA president (2015-2016), Thelma Duffey helped to guide the discussion as the Governing Council considered the portability model motion. She calls the adopted model aspirational and forward thinking, and terms the plan a form of advocacy in and of itself.

“One of our goals in endorsing the model for consideration by states was to enthusiastically promote ACA’s position on portability while working with stakeholders who shared our interests and visions. It was also important to the Governing Council that we alert the membership of our vision and mission to make licensure portability a reality,” says Duffey, professor and chair of the counseling department at the University of Texas at San Antonio. “Much like ACA’s aspirational goal of seeing counseling licensure reach every state years ago, we once again are aspiring to establish a national standard, and our goal is to see this realized in the future.”

As for next steps, Duffey says, “ACA is engaging in communication and advocacy efforts that involve informing the membership and other stakeholders about the ACA Licensure Portability Model … and communicating the challenges to portability, particularly as they relate to differences in initial licensure requirements across states. The Governing Council also approved an advocacy plan that highlights the trend toward standardization and provides a rationale for why the ACA portability model is a well-suited aspirational goal. The ACA plan is, of course, grounded in respect for state sovereignty and recognizes that each state licensing board has the ultimate decision on whether to participate. Next steps involve ACA working with states to facilitate support for standardization and the ACA Licensure Portability Model.”

“This model is, from my perspective, visionary in that it takes into account the increasing standardization of training and postgraduation supervision requirements,” Duffey continues. “It is also inclusive of all independently licensed professional counselors, and it is respectful of the training that counselors undergo. Moreover, it is designed with the intent of protecting the public. A criteria of the model stipulates that portability is contingent upon a violation-free practice.”

Multiple ideas, one goal

The ACA Licensure Portability Model joins another initiative that is being floated across the profession to address this issue. A plan co-created by the American Association of State Counseling Boards (AASCB), the National Board for Certified Counselors, the Association for Counselor Education and Supervision, and the American Mental Health Counselors Association endorses allowing licenses to be transferred between states for counselors who have “engaged in ethical practice, with no disciplinary sanctions, for at least five years from the date of application for licensure endorsement” and “possessed the highest level of counselor licensure for independent practice for at least three years from the date of application
for licensure endorsement.” Licensees would also have to comply with one
of the following:

  • Hold the national certified counselor credential in good standing
  • Have a graduate-level degree from a program accredited by the Council for Accreditation of Counseling and Related Educational Programs
  • Meet all of the academic, exam and postgraduate supervised experience standards as adopted by the respective state counseling licensure board

Prospective licensees would also have to complete a jurisprudence exam if required by the state’s regulatory board. As with the ACA model, this plan would first have to be adopted state by state to come to fruition.

“A set of guidelines, as with the ACA Licensure Portability Model that Governing Council embraced in June 2016, is a positive and necessary gesture in support of the standardization of licensure to enable licensed counselors to move from state to state with a maximum of ease,” says 2016-2017 ACA President Catherine Roland. “The operative word in that sentence is guidelines, because any portability model … is at best [a set of] respectful professional suggestions to state boards. So while portability is a priority for all of us, the state boards would need to be willing to work to create a similar template for all, and that I feel is aspirational.”

“I also believe it is an attainable goal in the future,” Roland continues. “That goal may be reached, however, and still not ensure the actual ability of an individual to be licensed in a particular state. It’s important to realize that each state board will continue to carefully check each and every applicant, in much the same way as they do now. If someone doesn’t have the requirements of academic or practice rigor, it is very likely that no license will be granted. Portability doesn’t guarantee a license.”

A vision for the future

During her presidency, Duffey created a task force focused on counselor license portability, led by 2014-2015 ACA President Robert Smith. Duffey says she directed the group to evaluate other portability plans circulating within the profession “for potential ACA adoption of those models. If the task force did not see a compatible fit between those existing models and ACA’s strategic vision, the task force was given the latitude to create a model that more closely aligned with our vision for the future.” The task force decided to create a separate ACA model, which was ultimately passed by the Governing Council.

As Duffey explained, “The portability task force was charged with developing the model that considered the extensive training and supervisory experiences of counselors, and the great needs for mental health counseling. They also recognized the strong trends toward licensure standardization with regard to education and experiential requirements. The task force believed that the ACA portability model would meet the needs of counselors as the requirements become more uniform across the country. It would be very unfortunate for states to adopt a portability plan that involved additional post-licensure years of experience only to have this requirement unnecessary in the near future.”

Duffey says she views the ACA Licensure Portability Model as addressing the problem of state-to-state portability by providing states with “a visionary best practice promulgated by ACA. Although this can be seen as a tall order in the short run, I believe it will be a wonderful accomplishment and form of advocacy in the long run. Most state licensing boards require 60 hours of course work and 3,000 hours of post-master’s-degree supervision at this point in time. We are making strides toward standardization. As a result, I believe we are well-positioned to move the ACA Licensure Portability Model forward for consideration by states. It may be that we begin this work through compacts, or states that share common requirements.”

Building on a foundation

In 2015, ACA sent letters to state licensing boards asking for the adoption of a uniform professional title — licensed professional counselor (LPC) — and a uniform scope of practice, a five-paragraph job description that defines the work of professional counselors. The letter was the culmination of the Building Blocks to Portability Project that was part of 20/20: A Vision for the Future of Counseling. The yearslong strategic planning initiative, co-sponsored by ACA and AASCB, involved 31 counseling organizations. (For more information on 20/20, including the Principles for Unifying and Strengthening the Profession, the consensus definition of counseling and the Building Blocks to Portability Project, see counseling.org/knowledge-center/20-20-a-vision-for-the-future-of-counseling.)

Counselor licensure requirements were set up individually by each state over a period of decades — beginning with Virginia in 1976 and ending with California in 2009 — as the profession matured and pushed to establish itself. In the process, significant disparities arose between counselor licenses across the United States, from the number of supervision hours required to obtain a license to the license titles themselves, creating many of the ongoing obstacles in licensure portability.

“ACA is committed to working through these obstacles,” Duffey says. “It is a real burden that licensure portability is not available for a very large majority of independently licensed counselors at this point. As counselors, we cannot move from state to state with any assurance that we can practice and do the good work of counseling. This is so even after investing countless hours in training and supervised practice. Should independently licensed counselors need or desire to move to a different state, they risk losing the opportunity to work within their profession. This is a real challenge that too many people must deal with. Therefore, I see licensure portability as an important need and promoting licensure portability as an important professional goal.”

Says Roland, “I do believe licensure portability is a goal we all have, and I believe eventually it will be a goal that is reached. Until then, we will continue to support our ACA Licensure Portability Model and uphold our ACA Code of Ethics while we remain loyal to the counseling profession.”

 

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Text of the ACA Licensure Portability Model (as adopted by the ACA Governing Council)

“Whereas the mission statement of the American Counseling Association is to enhance the quality of life in society by promoting the development of professional counselors, advancing the counseling profession, and using the profession and practice of counseling to promote respect for human dignity and diversity; and

“Whereas advocating for licensure portability that allows professional counselors licensed at the independent practice level in one state to have the mobility to utilize their education and training and to serve the public by becoming licensed at the independent practice level in another state supports the mission of the American Counseling Association;

“Therefore, the American Counseling Association promulgates the following licensure portability model:

“A counselor who is licensed at the independent practice level in their home state and who has no disciplinary record shall be eligible for licensure at the independent practice level in any state or U.S. jurisdiction in which they are seeking residence. The state to which the licensed counselor is moving may require a jurisprudence examination based on the rules and procedures of that state.”

 

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Letters to the editor: ct@counseling.org

 

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See ACA’s list of frequently asked questions on portability, as well as an email address you can contact with further questions, here: counseling.org/knowledge-center/aca-licensure-portability-model-faqs

 

Helping clients build their life rafts

By Angela Frank June 5, 2017

How can you judge the value of a life raft if you can’t measure the impact of the waves, the harshness of the current or the depth of the water? For clients, being in the midst of chaos feels like being in the middle of the ocean with no vessel, flailing arms in hopes that someone might see and help.

It can be hard to determine where to start to get out of a bad situation. But with the help of professionals, clients learn how to slowly build their life rafts. Not all results are immediate. It can take years for a counselor’s impact to become apparent in a client.

When I was a client in counseling as a minor, I’m sure that the helping professionals in my life questioned whether they were making any impact on me. They would likely be surprised to find that not only did they have an impact, but that I have made it my mission to pass on what I learned from them.

I remember the first time a school counselor told me that I could not only graduate from high school but that I could also go on to college. I had assumed that opportunity was lost to me because I had previously dropped out of school. No one else had ever told me it was still a possibility. I still remember the way I felt when I heard this news. I was crying because, in that moment, I felt more hope than I had felt in a very long time.

I had been subjected to a life that was excessively chaotic. Between elementary and high school, I moved eight times, was interviewed by child protective services (CPS) social workers in two different states, had to stay with a stranger while my mother was in rehab and was fostered by two other families (being removed by court order from one of them).

Upon graduating from high school, I was floored to find out that children in similar situations do not often go to or finish college. After graduating with both my bachelor’s and master’s degrees and becoming licensed in counseling, I feel safe to say that I beat the odds and the expectations of many. I can’t stress enough that I could not have accomplished these goals if it wasn’t for the professionals in my life.

The list of coping skills presented in this article may be useful in working with adolescents and adults who have had childhood trauma, but they may not work as well for people who are still in the throes of chaos. This list is best used with clients who are at a place in their lives in which they are feeling safe and no longer feeling threatened by their attackers.

Many of the action points on this list are considered therapeutic techniques, but I used them before I knew they were taught as techniques to counselors. My hope is that this list will help other counselors who might feel lost in their practice or off course with a client to find direction once again.

The following skills constitute the foundation of my life raft.

 

1) Making a timeline

For someone who has had a chaotic childhood, time might seem like an abstract concept. Collecting documents can help these clients piece memories together, make past events feel more real and provide an outside, unbiased perspective into what was happening to and around them. Documents also can be used as a tool when confronting family members who deny or don’t want to face reality.

In Washington state, anyone can search online for court case files and request public records. I have been requesting my childhood records because I need help understanding what happened in my life. I collected as many records as I could find related to my past. These include court records, CPS records, police reports and mental health evaluations.

Obtaining records has been a struggle, but it has also been one of the most important steps in confronting my trauma. They serve as a concrete reminder that, as unbelievable as it all seems, what I remember from my childhood really happened. I was able to obtain one record from CPS but was informed a previous record had been destroyed before I even knew it existed. In many states, CPS doesn’t have to inform the subjects of records that the records exist before destroying them. The records told me about the abuse I remember and didn’t report when, as an adult, now I know I should have.

My mother let me know that anything left at her house from when I was a child is gone, so these records are all I have of my past. I haven’t talked to her in six years. I offered to show my younger sister the records because she was very young when the chaos ensued and doesn’t remember a lot. I believe this step has helped both of us.

2) Sharing my story

Listening is the most basic counseling technique any professional is taught, and talk therapy is the place where trauma victims really need to start. Listening is a tool that can be used to gain the trust of clients who normally keep their thoughts on lockdown. For me, having someone there literally just to listen — who didn’t know my family, wasn’t going to tell them what I was talking about and wasn’t going to judge me — was such a relief.

My counselor had to push me a little bit to get me to talk about the trauma. I brought my counselor a copy of my CPS records and let her look at them. It was easier than saying what had happened to me. I didn’t know how to bring it up myself. I had avoided telling her that I had a traumatic childhood because I had come to counseling (or so I thought) for a different reason. After she read my records, I felt she had a better understanding of why there were destructive patterns in my life.

3) Confronting the shame

After trust is gained, clients feel more comfortable talking about how they have treated others in response to what has happened to them. This is important because clients who come from dysfunctional families might fear backlash. Their family members may have tried to use these incidences against them for blackmail or as a “guilting” technique in the past. Just the thought of bringing this up and the potential resulting scrutiny can put clients on edge.

Talking about guilt in a therapeutic setting can help clients to see patterns of shaming and let go of their guilt little by little. Once clients can acknowledge that they have hurt others, it can open up conversation about how these clients are now different. They recognize that how they treated others was wrong and can reassure themselves that it won’t happen again.

This process gives clients back the power. Shame can no longer be used against them once they recognize that part of the reason they can talk about it now is because they have taken steps to change their destructive behaviors with others and are interested in constructive interactions.

It is really hard to acknowledge when you’ve wronged someone. I had memories of how I had wronged people that haunted me for years. When I finally was able to talk about these memories with my counselor, I never sensed that she judged me for what I had done. It was such a relief to finally be able to tell someone who wasn’t going to judge me for actions I had taken when I was a kid and was in a bad place.

4) Normalizing

As a counselor, normalizing is an essential technique, but there are appropriate and inappropriate ways to use it. It is appropriate to use normalizing to help clients recognize that they reacted harshly to a situation because that is how they grew up — as long as they are taught or have learned more constructive ways to handle tough situations. Children have little control, but adults are more responsible for their behavior. Discussing how destructive reactions are inappropriate as an adult is important.

After I told my counselor about what I was ashamed of and how I had treated people, she would normalize it for me, saying, “In this situation, it would be normal for you to have this reaction given your history.” When she told me that, it helped me put into perspective how the trauma affected me and why I would resort to taking certain actions instead of dealing with issues in a more functional manner. From this step, I have been able to deal with my anger, panic, and numbness in more constructive ways.

5) Practicing altruism

Clients may not always be in a position to help others financially, but there are plenty of other ways to help every day. Encourage clients to find those small but meaningful opportunities. It has been therapeutic for me to be there for my younger sister, both financially and emotionally, the way I would have liked someone to have been there for me. When I was removed by court order from a family member’s home, I didn’t get to see my sister for five years. Even though she doesn’t blame me and is understanding, this is how I am trying to make up for missing all that time watching her grow up.

6) Making amends

When clients tell their counselors about their guilt, they might feel depressed for a while after. Admitting that you hurt someone, even if it wasn’t on purpose, might not feel like enough. The next step might be apologizing in a way that feels fitting to the client. Not everyone gets a chance to face their victim and apologize, so writing a letter (which might be kept or sent to the victim, depending on whether the client feels the apology would benefit the other person) can be a very healing experience.

In dealing with my guilt, I apologized to family members because, in my agony, I hadn’t thought about their feelings or how I treated them. I offered that if they ever felt the need to confront me, I would be open to meeting with them. It has helped me to imagine these interactions beforehand. So far, none of my family members has felt the need to confront me. Instead they have told me either that I do not need to apologize or that they have forgiven me, which has brought me closure.

7) Discovering gratitude

For clients in the midst of depression or anxiety, it can be hard to elicit any positive feelings. It’s most important during these times to be grateful because the affect can snap a person out of the emotion. Making a list of what the clients have that they would be worse off without or the things they don’t want to change is a good place to start. This might also jog some really good memories, and clients might end up wanting to reach out to people. The internet is a useful tool for people searching and reaching out when the time comes.

Clients who haven’t been able to confront their past or who still feel guilt and shame might not be able to remember the people who helped them yet. Give it time — it’s a process.

I decided to use the internet to try to connect with people I remember showing me kindness when I was in despair. From becoming grateful, I was able to have more affectionate feelings toward my family and started recognizing the little things they had done to help me along the way.

Even though my mother was not in a position to care for me at times when I was a child, there are things she did that showed that she loved me and cared about me. When the time came, she gave me her tax information so I could fill out the Free Application for Federal Student Aid to finish college. She also told me I wasn’t crazy even when I was convinced I was. These actions don’t make me want to talk to her, but they do let me know that she wanted to keep me moving forward. I wasn’t able to be grateful for these little acts until I could fully accept all the trauma and stop trying to hide it from myself and everyone else.

8) Having faith

It’s well-known that possessing faith can literally keep someone alive. Being able to turn life circumstances over to a higher power can be a profoundly impactful internal resource. For me, this takes some of the pressure off regarding the goals I want to achieve. I keep working toward my goals, but it helps to have faith that forces are at work (even if I don’t understand them), giving me the power to push to get the things I want. When I’ve done all I can, that’s the time for me to just turn it over to the universe to let it take care of what I no longer have control over. I have stopped trying to maintain control of everything and have started to just let things happen.

It doesn’t matter if your faith is in a Christian God, Buddhism, Judaism, fate, Unitarian Universalism or some other system. Just having faith and truly believing that there is some bigger force out there that can’t be taken away can make a positive impact on an individual’s life.

9) Reconnecting with community

Everyone has days when he or she would rather just sit alone at home and watch TV or be on the computer. Over time, this can result in feeling disconnected and lonely. It can even be triggering, making clients feel more isolated than they actually are.

Tell clients that you understand that it can be hard to get out at times. But also remind them that simply being with others can provide a welcome distraction, result in meeting personal goals, and lead to positive feelings and new opportunities. For frugal clients, there are plenty of free events, but this might require some research.

For me, forcing myself to become part of a community and visit friends even when I didn’t feel like it made all the difference. I ended up being grateful I had made myself go. If clients tell you this same thing, talk extensively about what happened that made it a positive experience for them. This will encourage the new behavior.

10) Engaging in advocacy

There are plenty of marches going on in America right now as a way to advocate for what many believe in. Advocacy creates unity between people with similar goals, creates community, brings hope and empowers. Counselors can help by searching for groups or communities with a purpose that would help their clients move forward from their past.

I case manage children in foster care and get triggered at work sometimes because some of the stories I hear feel similar to mine. I can physically feel my heart hurt. To deal with this, I remember that there aren’t many professionals who can relate to what children in foster care go through the way I can, so I draw on my personal experience to advocate for and understand them.

11) Using a mantra

Having a reminder of what’s often forgotten or overlooked in the midst of chaos can be very comforting. This can help clients who feel stuck to keep going. When things are hard in my adult life, one thing that keeps me going is remembering that I survived much worse as a kid and have only grown stronger.

 

 

Conclusion

When people stop denying or minimizing their trauma and face their fears head-on, the resulting calm and insight are greater than the numbness brought on by burying the past. We all have our methods of coping; sometimes our coping strategies are so unique to us that we can’t even put a name to them.

Counselors have the ability to help clients find their strengths. The hard work results in feeling so empowered that clients may prefer to remember what they have already survived rather than trying to forget and feeling powerless over what they are experiencing now or will experience in the future.

Keep in mind that anyone who is sitting in front of you as a counselor has already survived a lot. Their arms are flailing for help, but they haven’t given up. There is still a chance for them. Using the techniques in this article, you have the power to help them build their life raft. You have the power to support them and be there for them as they look back on the chaos they survived, so that they can finally be free from it. Now that I have reevaluated my personal history, I want to help others recover from their own fears and trauma.

It took a long time to get to this place where I can finally face my past and not feel devastated. But now that I have, I would rather live in a cardboard box than ever deny myself again. When I tried to ignore my past, all it did was trigger me. It did not help me or those around me. I had so much anxiety that it was hard to function daily. I forgot why I was doing what I was doing and what my goals were in life. When I finally faced it head-on, I was able to reclaim myself, my confidence and my internal compass. Without the guidance I received from the helping professionals in my life, I would not be where I am today.

It might seem that some children are set up for failure, but counselors can help them find the strength within themselves to overcome. Take it from someone who knows. Anyone who is reading this possesses the power to change the course of someone’s life. Remember that.

 

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Angela Frank is a licensed mental health counselor in Washington state. She graduated from Washington State University with a Bachelor of Science in psychology and a Masters of Arts in education. She recently started a blog at highlymobilechildawareness.com and can be contacted at angela@highlymobilechildawareness.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.