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Eating disorders
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Solution-focused brief therapy
ACA President Cirecie West-Olatunji
The Spiritual Integration Toolbox
Becoming a mental health manager
CT0713_CT0713 4/11/13 3:22 PM Page 1
A counselor sued
for slander
triumphs in court.
A 52-year old physician arrested
for DUI, denies the counselor’s
assessment of substance abuse
and sues for slander and
$700,000 in damages.
Read the details of this case
study involving a malpractice
lawsuit against a counselor
insured through HPSO at
www.hpso.com/ct1.
This program is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company, and is offered through the Healthcare Providers Service Organization Purchasing
Group. Coverages, rates and limits may differ or may not be available in all states. All products and services are subject to change without notice. This material is for illustrative purposes
only and is not a contract. It is intended to provide a general overview of the products and services offered. Only the policy can provide the actual terms, coverages, amounts, conditions
and exclusions. CNA is a registered trademark of CNA Financial Corporation. Copyright © 2013 CNA. All rights reserved.
Healthcare Providers Service Organization is a registered trade name of Affinity Insurance Services, Inc.; (AR 244489); in CA, MN & OK, AIS Affinity Insurance Agency, Inc. (CA 0795465);
in CA, Aon Affinity Insurance Services, Inc., (0G94493), Aon Direct Insurance Administrator and Berkely Insurance Agency and in NY and NH, AIS Affinity Insurance Agency.
© 2013 Affinity Insurance Services, Inc.
CT0713
Endorsed by:
Counselor’s Professional Liability Insurance
Learn the value of having your own ACA-endorsed plan by visiting
www.hpso.com/ct1
Counseling
Today
Counseling Today
July 2013
Cover Story
30
Body language
By Lynne Shallcross
Even if counselors don’t specialize in eating disorders and body image, statistics
show they need to embrace their roles in preventing, detecting and treating these
issues that stretch across racial, cultural, gender and age lines.
Features
42
Keeping it brief
By Stacy Notaras Murphy
Solution-focused brief therapy builds on client strengths and aims for positive
outcomes rather than arriving at a complete understanding of the client’s past.
48
A counseling leader’s unlikely path
By Heather Rudow
It took Cirecie West-Olatunji several years and several job changes before she
discovered her calling as a professional counselor, but now she is ready to take the
helm as the 62nd president of the American Counseling Association.
52
Knowledge Share
Taking the lock off the Spiritual Integration Toolbox
By Michelle J. Cox
Clinicians sometimes need to be reminded that religion and spirituality are
important dimensions in counseling regardless of the presenting problem.
58
Reader Viewpoint
The education of a counselor-manager
By Christie Melonson
Graduate school doesn’t necessarily prepare you to become a manager in a
mental health setting.
62
Opinion
What you don’t know could hurt
your practice and your clients
By Elaine Johnson, Larry Epp, Courtenay Culp, Midge Williams & David McAllister
The boards of the Maryland and Massachusetts chapters of AMHCA offer their
joint perspective on implications of CACREP-only language in emerging policies.
30
42
48
July 2013 | Counseling Today | 3
Counseling
Today
Counseling Today
July 2013
Columns
Much more than
an online community
10 Washington Update
AC ACONNECT
11 The Two-Minute Advocate
12 Pages of Influence
16 Private Practice Strategies
18 Deconstructing the DSM-5
23 Risk Management for Counselors
24 Through a Glass Darkly
26 New Perspectives
28 Counselor Career Stories
In June, the American Counseling Association launched ACA Connect,
a new member benefit based on your requests, your input and your
feedback. This online networking tool allows you to find friends and
colleagues with similar interests, contribute practical tips and ideas,
ask questions and get answers in real time, share powerful education
resources, see who is attending events, watch brief instructional videos
and much more. Start a blog, search for someone you met at the ACA
Conference or browse interest-based forums to build your skill set. ACA
Connect is private and secure, for ACA members only. Customize your
profile and get started by visiting counseling.org. Simply click on “ACA
Community” and then “ACA Connect.”
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Need to Know
5 From the President
7 Executive Director’s Message
8 Letters to the Editor
45 CT Learning Test 57 Bulletin Board
66 Division, Region & Branch News
In May, the American Psychiatric Association
published the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5).
Shortly before the manual’s release, Counseling
Today polled online readers and asked the following
question: As a counseling professional, how do you
view the upcoming release of the DSM-5?
Among the 136 voters who responded to the nonscientific poll at
ct.counseling.org, the results were as follows.
n 20 percent (27 votes) viewed the DSM-5 in a positive light.
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11 percent (15 votes) viewed it in a negative light.
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9.5 percent (13 votes) viewed it with indifference.
59.5 percent (81 votes) said they wouldn’t form an opinion until they
had reviewed the new edition.
ACA and Counseling Today know that many counselors want to obtain
a better understanding of the changes in the DSM-5. That’s why we are
debuting “Deconstructing the DSM-5,” a monthly column that will offer
an in-depth look at the new manual. Turn to page 18 for the inaugural
column, and email us your feedback at [email protected].
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From the President
Cirecie West-Olatunji
Unapologetic
in our identity
O
ne of the most disheartening
experiences I have had as
a counselor educator was
overhearing a counselor sound ashamed
and apologetic about our profession.
Admittedly, counselors do experience
a disproportionate amount of
marginalization within the mental health
community. When we take a look at
the job descriptions, we are noticeably
absent or overlooked. Additionally, many
administrators at Department of Veterans
Affairs hospitals still refuse to hire licensed
professional counselors. In schools,
principals continue to expect professional
counselors to arrange scheduling, administer
tests and substitute teach. Plus, there is a
lack of acknowledgment of professional
counselors by key government agencies.
Even more discouraging, the general
population is unaware of what professional
counselors do or who we are. It is no
wonder that some counselors prefer to align
themselves with other professions such as
psychology or social work, or use more
generic terms such as “therapist,” when
experiencing microaggressions related to
their counselor identity.
However, despite these disparaging
truths, we should be unapologetic about
our identity as counselors. Our unique
contributions to the mental health field are
many. The assumptions that undergird our
philosophy about mental health include
the fact that we are, first and foremost,
humanistic. This implies that we are
respectful, client-centered and culturecentered. We have an undying faith and
belief in our clients’ abilities to self-actualize.
These tenets fuel our unconditional regard,
encourage awareness of our own lived
experiences that make us vulnerable to biases
toward our clients, and lay the foundation for
authentic engagement with our clients.
We are also uniquely developmental as
clinicians. This developmental focus allows
us to consider the role that human growth
plays in the presentation of client symptoms. Thus, we see clients as dynamic rather
than static — a moving target, if you will.
We recognize that our conceptualizations
of clients must be continual. We are also
oriented toward prevention and recognize
the value of working with nonsymptomatic
individuals. This allows us to reinforce lifesustaining behaviors among individuals who
are making good choices to afford them
more intentionality in their lives. Prevention-oriented counseling also allows us to
reinforce the resilient members within communities. These members can, in turn, serve
as models and leaders within their systems.
Professional counselors are also holistic
and ecosystemic in outlook and action. We
view clients within their environments and
consider the interaction effects between the
two. Thus, it becomes important to consider
not just intrapsychic influences but also
environmental factors that influence client
behaviors and attitudes.
Finally, we espouse a wellness philosophy
and reject the medical model of mental
health service delivery. We see individuals as
high functioning or low functioning on the
basis of life stressors such as work demands,
familial conflict, retirement, death of a loved
one, divorce and developmental transitions.
All in all, we bring a remarkable cluster of
skills to the field of mental health.
So, we should hold our heads high,
knowing that we have something unique
to share with our colleagues in sister
professions such as social work, psychology
and psychiatry. For clients, we offer clinical
experiences that are more organic and
intuitive to everyday living. Our interactions
often feel less intrusive and can be more
expedient than traditional models of mental
health service delivery.
I, for one, am glad to be a counselor
and take pride in my professional training,
worldview and identity. I am unapologetic in
my counseling identity. How about you? u
Counseling Today
Counseling Today Staff
Publisher
Richard Yep
Associate Publisher
Carol Neiman
Editor-in-Chief
Jonathan Rollins
800.347.6647 ext. 339
[email protected]
Associate Editor and Senior Writer
Lynne Shallcross
800.347.6647 ext. 320
[email protected]
Staff Writer
Heather Rudow
800.347.6647 ext. 307
[email protected]
Senior Graphic Designer
Carlos J. Soto II
800.347.6647 ext. 377
[email protected]
Contributing Writer
Stacy Notaras Murphy
Advertising Representative
Kathy Maguire
607.662.4451
[email protected]
CT Column Editors
Washington Update
Scott Barstow
Counselor Career Stories
Rebecca Daniel-Burke
Danielle Irving
Private Practice Strategies
Anthony Centore
New Perspectives
Donjanea Fletcher Williams
The Digital Psyway
Marty Jencius
Through a Glass Darkly
Shannon Hodges
Risk Management for Counselors
Anne Marie “Nancy” Wheeler
Technology Tutor
Rob Reinhardt
Deconstructing the DSM-5
Jason H. King
July 2013 | Counseling Today | 5
Instructive DVDs for Your Practice or Classroom
Rooted Sorrows—Emotional Burden to
Emotional Health: Veterans With PTSD
presented by Mitchell Young
In this compelling and heart-wrenching DVD,
Mitchell Young, a licensed psychotherapist and
combat veteran who has counseled Vietnam
veterans for more than 15 years, discusses PTSD
and the lasting effects of combat and severe
trauma. Drawing from his own experiences in
Vietnam as a member of the Marine Corps, he
examines the emotional scars that occur after a
traumatic event, night terrors, chronic isolation,
emotional numbness and complex and secondary PTSD. Produced by
R-Squared Productions, LLC • 2010 | 50 minutes | DVD Order #78241
List Price and ACA Member Price: $59.95
Breakthrough: Art, Analysis, & the Liberation
of the Creative Spirit
This inspiring film captures the experience
of eight artists of varying ages who have been
in therapy. It demonstrates the growth and
freedom made possible by facing the pain that
both psychoanalysis and creativity can bring
to awareness. The artists in Breakthrough—a
sculptor, a writer, a musician, three painters, and
two visual artists—had found themselves held
back in their lives and work because of traumatic
events and unresolved emotional issues from the past. Through
moving scenes that examine their individual therapeutic issues and
healing process, the DVD shows how the combination of therapy and
creative work liberated them professionally, emotionally, and spiritually.
Sponsored by the Lucy Daniels Foundation. Produced by Expressive
Media, Inc. • 2011 | 50 minutes | DVD Order #78242
List Price and ACA Member Price: $59.95
Quality Circle Time in the Secondary School
presented by Jenny Mosley
In this DVD, Jenny Mosley presents her classroom
behavior management model Quality Circle Time,
which encompasses a whole-school approach
to enhancing self-esteem and building positive
relationships. Through exercises with a group
of students, she teaches the skills, crucial steps,
and key ground rules essential to effective circle
time. The group session is followed by a teacher
question-and-answer session. Includes a PDF of
Mosley’s book Important Issues Relating to the Promotion of Positive
Behavior and Self-Esteem in the Schools, as well as lesson plans and
discussion points. Produced by Loggerhead Films
2010 | 60 minutes | DVD Order #78240
List Price and ACA Member Price: $129.00
Bullying in Schools: Six Methods of Intervention
presented by Ken Rigby
Ken Rigby, an international expert on peer
victimization, gives clear, practical guidance on
how to prevent and respond to bullying in high
schools. Using actors and role play, the DVD
features a typical bullying scenario and then
demonstrates how the following six methods
can be applied to the situation: the Disciplinary
Approach, Restorative Practice, Strengthening
the Victim, Student Mediation, the Support
Group Method, and the Method of Shared Concern. By showing the
advantages and weaknesses of each method, the counselor or teacher
can see how each possible solution might work. Includes a PDF with
a summary of important information and discussion guidelines.
Produced by Loggerhead Films • 2009 | 35 minutes | DVD Order #78239
List Price and ACA Member Price: $129.00
Practical Strategies for Caring for Older Adults: An
Adlerian Approach for Understanding and Assisting
Aging Loved Ones
presented by Radha Janis Horton-Parker and
R. Charles Fawcett
This DVD offers caregivers, counselors, and
educators effective strategies to improve the
lives of older people. Horton-Parker and Fawcett
discuss the characteristics of older adults, followed
by typical situations encountered by caregivers.
Engaging vignettes and presenter commentary
illustrate the underlying needs and mistaken goals
of attention seeking, power, revenge, and assumed
inadequacy that often cause perplexing behavior
in older people. The presenters’ simple techniques create win-win
situations between caregivers and aging loved ones that improve the
quality of life. • 2010 | 120 minutes | DVD Order #78238
List Price: $119.95 | ACA Member Price $99.95
6 | ct.counseling.org | July 2013
Please include $8.75 for shipping of the first DVD and
$1.00 for each additional DVD.
Order by phone: 800-422-2648 x222
M–F, 8 a.m.–6 p.m., ET
Order online: counseling.org/publications
Executive Director's Message
A special welcome
to current, new and
potential leaders
Richard Yep
E
ach July, ACA welcomes a
new president who will serve
for the next 12 months as
our association’s leader and primary
spokesperson. For the past 16 years,
I have had the honor of being the
person who works most closely with the
association’s chief elected officer to carry
out the organization’s strategic mission.
Our 62nd president is Cirecie WestOlatunji, and we welcome her to this
new role.
Similar to her predecessors, Cirecie is
quick to say that this will not be “her
year” so much as it will be “our year.”
Her hopes, vision and aspirations for the
next 12 months were reached after much
discussion, interaction and dialogue
with ACA members and leaders from
throughout the country and around the
world.
I have known Cirecie for a number
of years. My sense is that she intends to
bring together groups and individuals
to generate the best possible ideas and
actions for promoting the counseling
profession and honoring its commitment
to social justice for the good of those
whom our members serve.
To those of you who are also assuming
new leadership roles in July, I want to say
congratulations for committing to serve
at the branch, region, division, national
or international level. Simply saying “yes”
to the call to serve invigorates those of us
who will be working with you.
And what would a column on new
leadership be if I didn’t also reach out to
those of you who have perhaps thought
about how you might get involved with
ACA? As the association continues to
grow (as it has for an extended period
of time), more opportunities make
themselves available. As I have said
before, you don’t need to commit hours
and hours each month to be an ACA
volunteer. In fact, if you tell us you have
only one hour available each month to
serve, we will do our best to find a place
that offers a meaningful experience for
you. To find out what is possible, contact
ACA Director of Leadership Services
Holly Clubb at [email protected].
Volunteering and being a part of
the “ACA experience” is not just for
“newbies.” If you have been a volunteer
or served in a leadership capacity in
the past, I understand how you might
have needed a bit of a break to focus
on that part of your life that pays the
rent. But I also sense that the time
away revealed how much some of you
missed participating in ACA’s volunteer
leadership program. You are still only
an email away from reconnecting and
allowing us to help you find a new place
to volunteer on behalf of the profession.
Please let us know of your interest
because we would love to have you back.
July is the beginning of ACA’s fiscal and
program year. As staff and volunteers,
we have worked hard over the past few
years to lay the groundwork for what will
happen during 2013-2014. This will be
our first full year with the new, awardwinning ACA website. We also recently
introduced our online ACA communities,
known as ACA Connect. This will serve
to bring together our committees, task
forces, interest networks and other groups
of professional counselors that want
to work on the many issues facing the
profession.
As I hope you know, approximately
nine months from now, ACA President
West-Olatunji will open our annual
Counseling Today
American Counseling
Association
President
Cirecie West-Olatunji
800.347.6647 ext. 232
[email protected]
President-Elect
Robert L. Smith
800.347.6647
[email protected]
Executive Director
Richard Yep
800.347.6647 ext. 231
[email protected]
Counseling Today (ISSN 1078-8719) is the
monthly magazine of the American Counseling
Association, 5999 Stevenson Ave., Alexandria,
VA 22304-3300; Telephone: 703.823.9800;
Internet: ct.counseling.org. Opinions expressed
in this magazine do not necessarily represent
opinions of the editors or policies of the
American Counseling Association.
Subscriptions are available for $150 for 12 issues.
Email: [email protected]
Americas: 1-800 835 6770
Europe, Middle East & Africa:
+44 (0)1865 778315
Asia: +65 6511 8000
Single copies are available for $12.50 each
by calling ACA in-house fulfillment at
800.422.2648 ext. 222.
Periodicals postage paid at Alexandria, Va., and
additional mailing offices. Postmaster: Send
address changes to ACA Member Services,
5999 Stevenson Ave., Alexandria, VA 22304.
All rights reserved, 2013 by the American
Counseling Association.
Editorial Policies
Counseling Today reviews unsolicited articles
written by ACA members for publication. Not
all articles will be accepted for publication.
Send articles or request a copy of the writing
guidelines by emailing [email protected].
Anti-Discrimination Policy
There shall be no discrimination against any
individual on the basis of ethnic group, race,
religion, gender, sexual orientation, age and/or
disability.
Mission Statement
The mission 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.
Continued on page 66
July 2013 | Counseling Today | 7
Letters
Articles that make a difference
As a counseling graduate student, I can’t
even begin to tell you how informative and
useful I find Counseling Today to be. I only
wish I would have started reading it earlier
in my graduate school “career.”
Recently, I came across Kim JohancenWalt’s Reader Viewpoint article, “Emerging
from the cave” (April). I was instantly
struck by her insightful and compassionate
perspective on assisting clients who come
to therapy feeling stuck, like prisoners of a
past over which they had no control.
As I read about one of the author’s
clients, I noticed many parallels with a
current client of my own in internship.
I decided to mimic Kim’s empathetic
reflection of her client’s past in order to
help her make sense of the impact it was
having on her current life. I also reached
out to Kim, who graciously provided
encouragement and useful suggestions to
move forward.
Although my client still has some work
to do, she is slowly coming to terms with
“who she was” and with the notion that
it is never too late to love herself and
become the person she wants to be. Just
recently, my client looked at me with tears
in her eyes and said, “I’ve spent 42 years
hating myself and beating myself up for
everything. And now, after coming here
for a couple of months, I can say that there
truly isn’t anything wrong with me. Maybe
there is hope after all.” I had to hold back
my own tears.
So, I would like to thank Ms. JohancenWalt and the rest of the contributors to
Counseling Today for providing real, lifechanging thoughts and perspectives that
I have used and will continue to use as I
develop into a successful therapist. You are
all making differences in ways you may
never have realized.
Stacy Blanchard
Counseling Intern
People House
u
As I commence the final year of my
master’s program in counseling, the title
“counselor with training wheels” seems
8 | ct.counseling.org | July 2013
most fitting. I can’t help but feel a little
wobbly as I engage in events such as
professional meetings and communicating
with experienced counselors in the field.
However, I have found that reading
Counseling Today provides an important
supplement to my course work.
Admittedly, I look forward to each issue in
the same way that Steve Martin’s character
in The Jerk portrayed receiving the new
phone book.
The first article I read upon receiving
the May 2013 issue was “The dawn of
a new DSM.” The changes made to this
important resource have sparked great
discussion and debate among my peers,
dividing students into two groups, Team
DSM-IV-TR and Team DSM-5. I am
thinking of having T-shirts printed. This
could be a moneymaker!
As I continued reading Counseling Today,
the Washington Update and Two-Minute
Advocate columns addressed important
legislation that would affect Americans
who receive Medicare benefits and those
counselors who deserve to be compensated
for the professional services they provide
to this population. These articles remind
the “training wheels” population of how
important advocacy is in our field as we
become professionals.
Finally, I ended by reading a piece
highlighting the 2013 ACA Conference
& Expo (“A celebration of counseling in
Cincinnati”). On page 64, I came across
a picture of a woman with a contagious
smile giving the thumbs up as she stood
in front of a sea of white paper. Each
paper provided an opportunity for
peer consultation, résumé critique or
interviews with employers during the
conference. While our nation’s economic
and unemployment recovery could be
compared to the children’s book The Little
Engine That Could, it is exciting to see the
profession of counseling is providing its
stakeholders with plenty of opportunities
for professional growth and guidance.
Those of us with counselor training
wheels receive tenacious support and
guidance from leaders in our field. This
provides a caliber of encouragement that
is unique among professions. The May
issue of Counseling Today provides evidence
in support of these essential relationships,
which will allow us to have a greater
impact on future generations in need of
empowerment toward healing.
Kimberly Phillips
Master’s of Counseling Program
Barry University-Orlando
Guidance worth sharing
I have appreciated several of the articles
written by Lynne Shallcross during the
past few months. Her article in May on
nonsuicidal self-injury (“When the hurt is
aimed inward”) is probably the best I have
ever read on the topic.
While I agree with one of the
individuals interviewed that the counseling
relationship is the integral factor in
treatment, the article covers self-injury
from many theories. I had never thought
about the externalizing slant. And I
couldn’t agree more about assessing
motivation. Ending self-injury has seldom
been my clients’ initial goal.
I work with domestic violence and
childhood sexual abuse survivors in an
agency and will share this article with
coworkers and interns.
Joan Dolan
Dallas
Living (and counseling)
by the Golden Rule
I have taught both ethics and diversity
classes in counseling programs at Regis
University and the University of Phoenix,
and the topic of religious beliefs as they
impact comfort level with different types of
clients has always come up and prompted a
lively debate.
Michelle R. Cox’s opinion article in the
May issue (“When religion and sexual
orientation collide”) makes some great
points. Perhaps the most important one
is the idea of people having different
interpretations of the Bible. This is also the
issue of spirituality/individual faith in God
versus organized religion.
There are counselors who are not just
Christians of different denominations,
but also counselors who are followers
of Islam, Buddhism, Judaism and
Hinduism, to name but a few. All of the
books of faith of each of those religious
movements have their own version of
the Ten Commandments and their own
version of the Golden Rule. If, in fact, you
profess to believe that we are all “God’s
children,” then we seem to be obligated to
treat our “brothers and sisters” with respect
and maybe even share our “God-given”
counseling skills with them in their time of
need, regardless of their sexual orientation,
among other things.
Ron Shaver, Ed.D., LMFT, NCC
Clinical Director, Serenity Mental Health
Las Vegas
[email protected]
Mending the rift
As an individual who is currently a
member of the National Rehabilitation
Association, the American Rehabilitation
Counseling Association and the American
Counseling Association, and who is also in
his first year of a rehabilitation counseling
program accredited by the Council on
Rehabilitation Education (CORE), I would
like to express sincere concern for the
rhetoric used in the most recent update on
the 20/20 initiative on counselor mobility
(“20/20 can’t reach consensus on education
requirements for license portability,” May).
When choosing a program, I was torn
between my background in rehabilitation
and my goals of becoming a counselor
with a transferrable license. I hope to work
primarily with people with disabilities, and
to that end, I chose my path. That said,
I have nothing but respect for what the
people in the Council for Accreditation
of Counseling and Related Educational
Programs (CACREP) are attempting to
do in increasing the overall standard of
counselor education to a well-balanced
60-hour program. I will be going out
of my way to take electives through my
university’s mental health counseling
program to make up the difference in
course work where I can.
I also believe in CORE’s valuing of a
varied educational background from which
they pull their core faculty members. I feel
that forcing their faculty members to have
attended a CACREP-accredited doctoral
program can limit the quality of education
by excluding experts in highly related
fields such as addiction, sociology and
psychology. As a student, I feel this issue
needs to be addressed in any discussion of
a merger.
Further, I was put off by the CACREP
suggestion that it might begin accrediting
its own set of rehabilitation counseling
programs. This came off to me as nothing
more than political muscle flexing in a field
where no single group has the requisite
power to get anything done. Using harsh
words and threats will only serve to further
fracture our growing field and further limit
our ability to compete with other helping
professions that have more unity. As social
work continues to grow, it is joined by
occupational therapy and other professions
that frequently find jobs and access to
insurance boards while counselors are being
left behind.
Despite my current concerns, I am
writing this with hope and faith in
my brothers and sisters in the field of
counseling. I believe we can mend this rift
with a dose of love and humility.
Letters policy
Counseling Today welcomes letters
from ACA members; submissions from
nonmembers will be published only on
rare occasions. Only one letter per person
per topic in each 365-day period will be
printed. Letters will be published as space
permits and are subject to editing for both
length and clarity. Please limit letters to 400
words or less. Submissions can be sent via
email or regular mail and must include the
individual’s full name, mailing address or
email address and telephone number.
ACA has the sole right to determine if
a letter will be accepted for publication.
Counseling Today will not publish any letter
that contains unprofessional, defamatory,
incendiary, libelous or illegal statements or
content deemed as intended to offend a
person or group of people based on their
race, gender, age, ethnicity, religion, sexual
orientation, gender identity, disability,
language, ideology, social class, occupation,
appearance, mental capacity or any other
distinction that might be considered by
some as a liability. ACA will not print letters
that include advertising or represent a copy
of a letter to a third party. The editor of
Counseling Today will have responsibility for
determining if any factors are present that
warrant not publishing a letter.
Email your letters to [email protected]
or write to Counseling Today, Letters to the
Editor, 5999 Stevenson Ave., Alexandria,
VA 22304.
Marvin Bellows
[email protected] u
July 2013 | Counseling Today | 9
Washington Update - By Scott Barstow & Jessica Eagle
TRICARE requirements narrow for independent practice
F
or several months, the managed
care support contractors charged
with administering the TRICARE
program have been certifying counselors for
independent practice. Counselors have been
covered by TRICARE for many years when
practicing under physician referral and
supervision, but TRICARE is transitioning
to a framework in which mental health
counselors practice independently, just
as other master’s-level mental health
professionals have been doing for decades.
Becoming a TRICARE certified
mental health counselor is not automatic,
however. Under the interim final rule the
Department of Defense (DOD) adopted in
December 2011, only counselors who meet
certain requirements will be recognized. It
appears the criteria for gaining certification
— and, hence, the ability to see TRICARE
beneficiaries in 2015 and beyond — are
narrower than previously thought.
The interim final rule stipulated that
counselors must have a master’s or higher
level degree “from a mental health counseling program of education and training.”
The rule uses this description both for
CACREP-accredited and regionally accredited degrees, although only CACREPaccredited degrees will be accepted beginning Jan. 1, 2015. Recently, the DOD
clarified that only degrees in “mental health
counseling” or “clinical mental health
counseling” qualify as being “from a mental
health counseling program of education and
training.” Thus, it appears that counselors
with degrees in community counseling,
counseling psychology or other areas will
not be allowed to see TRICARE beneficiaries independently and would be excluded
from the program entirely beginning in
2015, when counselor practice under physician referral and supervision is phased out.
Counselors have already expressed
concerns about other aspects of the
TRICARE certification requirements.
Although TRICARE will allow counselors
with degrees from regionally accredited
programs to become certified during the
transition period, those counselors must
pass the National Clinical Mental Health
10 | ct.counseling.org | July 2013
Counseling Examination, regardless
of which exam they passed to become
licensed. Another issue involves supervision
hours. The TRICARE regulation requires
two years/3,000 hours of post-master’s
supervised experience. Unlike the
requirements in most state licensure laws,
however, all of these hours must be under
the supervision of a licensed mental health
counselor. Supervision hours obtained under
licensed professionals other than a counselor
do not count toward the requirement.
At some point, the DOD will issue
a final version of its regulation, which
could feature changes to one or more of
these requirements. ACA has urged the
DOD to make it easier for counselors to
become TRICARE certified mental health
counselors, but, ultimately, Congress may
need to get involved.
Should all counseling degrees be
accepted? Should all supervision hours
recognized by your state’s licensure board
be counted? Should five years of clinical
practice, or documented training in
working with military populations, plus
licensure, qualify you for independent
TRICARE practice? If you believe the
requirements should be changed, please
ask your senators and representatives to
request that the DOD make those changes.
Ultimately, Congress has the authority to
override DOD rules. For more information,
contact Scott Barstow with ACA at
[email protected].
ACA submits recommendations
for landmark education law
House and Senate committees with
jurisdiction over education policy are
having long-overdue conversations about
reauthorization of the Elementary and
Secondary Education Act (ESEA), which
was last updated in 2001 as “No Child Left
Behind.” In the prior Congress, the Senate
developed a bipartisan reauthorization bill,
but without a similar bipartisan proposal
in the House of Representatives, the
reauthorization effort ran out of steam.
ACA has submitted recommendations
concerning ESEA reauthorization to
committee staff to increase support for
school counselors and school counseling
services. Recommendations include:
n Reauthorizing the Elementary and
Secondary School Counseling Program
and increasing funding opportunities for
mental health programs
n
Including language to help equalize
professional development opportunities
for school counselors with those
provided to administrators and teachers
Giving school counselors and other
support personnel a voice by establishing
an office of Specialized Instructional
Support Personnel within the
Department of Education
Although a lack of bipartisanship may
once again sink reauthorization, the
discussions provide an opportunity to
educate policymakers about the importance
and role of professional school counselors.
Our recommendations are online under
“Recent Updates” on the ACA public
policy website at counseling.org/publicpolicy.
Contact ACA’s Jessica Eagle at jeagle@
counseling.org with any questions.
n
Counselor Medicare bill
gains three cosponsors
Legislation establishing Medicare
coverage of licensed professional counselors
is slowly gaining support in the Senate.
Three more senators — Barbara Boxer
(D-Calif.), Dick Durbin (D-Ill.) and
Jon Tester (D-Mont.) — have signed
on as cosponsors of S. 562, the Seniors
Mental Health Access Improvement Act
of 2013. Until an actual vote takes place,
cosponsoring a bill is the only concrete
way legislators have of going on record
as a supporter. Legislation typically isn’t
brought up for a vote in a committee or
on the House or Senate floor unless it
has substantial support, so attracting a
significant number of cosponsors for a
legislative proposal can help ensure that a
vote happens. ACA continues working to
gain more cosponsors on S. 562 to increase
the likelihood of its inclusion in broader
Medicare legislation later this year. u
The Two-Minute Advocate - By John Yasenchak
Maine counselors convince
senator to cosponsor Medicare bill
M
aine counselors have been
working very hard the
past several months on
major legislative issues affecting both
our clients and the status of professional
mental health counseling. A plan to
eliminate licensed clinical mental health
counselors from being able to provide
services to individuals who are dually
eligible (meaning they have Medicare
and Medicaid) was proposed to the state
Legislature. The proposal was seen as a
cost-saving measure.
Members of the Maine Counseling
Association (MeCA) and the Maine
Mental Health Counselors Association
(MEMHCA) combined efforts to lobby
legislators on behalf of the counseling
profession. We argued that the proposal
would only shift costs to other providers,
cause harm by discontinuing alreadyestablished services, reduce access to
care and unfairly target clinical mental
health counselors in a state where parity is
already supposedly established.
The administration countered with
an alternative 5 percent reduction in
Medicaid reimbursement for services
provided by licensed clinical professional
counselors (LCPCs). The targeted
reduction focuses only on LCPCs. The
discussion continues and is scheduled for
a vote in the Legislature.
The commissioner of the Maine
Department of Health and Human
Services has argued that because LCPCs
are not reimbursable under Medicare, we
are the most reasonable group to cut. This
position has had a significant impact on
hiring practices in Maine, as well as the
aspirations of those who wish to serve as
LCPCs in our state. Some agencies do
not hire LCPCs, and when they are hired,
their scope of practice is limited — and
sometimes misunderstood.
This issue can be addressed in Maine
and across the country by passage
of the Seniors Mental Health Access
Improvement Act of 2013. This bill
in the U.S. Senate, introduced by Ron
Wyden (D-Ore.) and John Barrasso
(R-Wyo.), would establish Medicare
coverage for licensed professional
counselors and licensed marriage and
family therapists. With Medicare
enrollment projected to grow sharply over
the next 20 years, this bill would improve
access to care, while reducing costs related
to emergency room visits and treatment
of chronic conditions. It would also help
influence state-level policies.
This Senate bill needs a large number of
cosponsors to increase its chances of being
passed. In Maine, members of MeCA
and MEMHCA asked Sen. Susan Collins
to sign on as a cosponsor, and as a result
of our work, she listened to our request.
Recently, representatives from MeCA,
MEMHCA, Husson University and two
agencies met in person with Collins to
thank her and to encourage her to talk
with her Republican colleagues on our
behalf.
Professional service and identity
issues are not going to go away easily or
soon. But advocacy can work. It is so
important to give these concerns a public
voice. Networking and “bending the
ear” of state representatives and actively
exhorting our members of Congress is
essential. The lessons we have learned are:
1) If we do not speak up, we do not
exist.
2) Advocacy needs to be a part of our
professional identity and the result of
ongoing cooperation and conversation in
our profession. u
John Yasenchak, a licensed clinical
professional counselor, is the
president of the Maine Counseling
Association and an assistant
professor of counselor education
at Husson University.
Letters to the editor:
[email protected]
ACA THANKS OUR
SPONSORS!
AON
Bio-Medical Instruments, Inc.
California University of PA
Capella University
CounselingInternships.com
HPSO Insurance
Liberty Mutual
Loyola University Maryland
University of Phoenix
Walden University
July 2013 | Counseling Today | 11
Pages of Influence - By Rita Chi-Ying Chung
A foundation built on culture and comics
I
Rita Chi-Ying Chung, a
professor in the counseling and
development program at George
Mason University in Fairfax, Va.,
is the recipient of the American
Counseling Association’s 2013
Gilbert and Kathleen Wrenn Award
for a Humanitarian and Caring
Person and the 2012 ACA Kitty
Cole Human Rights Award. She
was also the recipient of the 2013
Virginia Outstanding Faculty
Award and a 2013 Commonwealth
of Virginia General Assembly
Commendation Award. She is a
consultant for Save the Children,
U.K., conducting training for
the organization’s staff, and has
also been invited to present at the
United Nations on the issue of child
trafficking. Contact her at rchung@
gmu.edu.
12 | ct.counseling.org | July 2013
t is such an honor to be asked by
Counseling Today to write about five
books that have influenced me. The
problem was, which five books to choose?
So many books came flooding into my
mind that it created a tsunami effect.
Should I include authors of color who
have influenced and shaped my racial
identity or those who have dared to speak
about multicultural counseling during
less receptive times? Do I include human
rights leaders who have inspired me
such as Aung San Suu Kyi, Steve Biko,
Gandhi, Martin Luther King Jr., Alice
Walker, Howard Zinn? The list is endless.
As with any book that I read, I have
decided to start at the beginning. I
did not start reading books written
in English until my adolescent years
because I struggled with learning English
as a second language. Reading books
in English was painful because with
almost every sentence I had to look
up a word in the dictionary, which
resulted in utter frustration. So, instead
of books, I gravitated toward comics.
As a child, I was enthralled with Tan
Tan (the Asian name for The Adventures
of Tintin, a Belgium comic series) and
dreamt of being in faraway places and
in the midst of electrifying adventures.
My older cousin Ting introduced me
to Mad magazine. I doubt that I fully
understood the deeper meaning behind
the satirical message of Mad, but as a
child, I was drawn by Alfred E. Neuman’s
zany sense of humor. Charles M. Schulz’s
Peanuts introduced me to the concept
of universality. Charlie Brown’s constant
struggle with Lucy resonated with me
as I faced challenges growing up in a
British colony (New Zealand). Charlie
Brown’s hope and determination also
promoted my resiliency and drive to free
myself from the shackles of being labeled
a slow learner by my teachers due to my
difficulty learning English. The comics
provided the foundations of who I am
and what I have become. They planted
in me the seed of adventure and social
justice and shaped my sense of humor at
a young age.
My personal and professional lives are
intertwined. As I searched for my racial
identity and meaning in life, I was also,
unbeknownst to me at the time, shaping
my professional career. As I grappled as
an adolescent with the meaning of life
and making sense of what sometimes
appears to be an unjust world, Lao Tsu’s
Tao Te Ching (1973) was particularly
influential to me, providing me with
major life lessons. Experiencing and
witnessing so
much inequality,
discrimination
and racism at
a young age, I
questioned why
some human
beings could
be so hateful,
hurtful and do
such heinous acts
to one another. I
could see myself
growing bitter, resentful and hateful, and
I was determined not to become what I
had witnessed and experienced.
Lao Tsu taught me valuable lessons
about forgiveness, patience and the
yin-yang of life. Seeing the world as
interconnected positives and negatives
led me to view life experiences and
challenges from a counseling prevention/
intervention perspective. Instead of
perpetuating the cycle of hatred by
responding in an equally cruel manner
when I witnessed ugliness in humankind,
I learned to counteract this through
forgiveness, love and kindness. As Lao
Tsu stated, “All can see beauty as beauty
only because there is ugliness. All can
know good as good only because there is
evil.” I interpreted the yin-yang concept
as displaying authentic empathy that
leads us to truly understand the reasons
behind acts of atrocities. Authentic
empathy then becomes a powerful tool in
prevention and intervention.
My first year as an undergraduate, I was
assigned Paulo Freire’s Pedagogy of the
Oppressed (1970). Though I struggled
with the difficult text, the words were
powerful. I still have a vivid memory of
making myself comfortable as I began to
read the book on a spring morning at the
library, anticipating a long and arduous
day ahead. Not knowing what I was in
for, I quickly became captivated, the
words exploding from the pages. I did not
move until I had
finished reading
the entire book
(thank goodness it
was a small book
because I am a
slow reader).
Freire’s words
moved me deeply,
motivated me,
inspired me,
and in that
second I knew my destiny. I wanted to
be involved in the fight for the rights
of disenfranchised and marginalized
communities. So, it is not surprising
that my work has focused mainly
on immigrants, refugees, human
trafficking and disaster counseling
from a multicultural social justice
perspective. Freire also influenced my
teaching. Similar to the experience of
others, I was subjected to the “banking”
concept of education, in which teachers
deposited information and students
received it passively. Freire provided
me the permission and courage to
utilize innovative teaching techniques
in counselor training that would
elicit in students critical thinking and
consciousness, creativity and courage to
take action — all the ingredients essential
to becoming multicultural social justice
counselors, leaders and advocates.
The third book that influenced me was
Maxine Hong Kingston’s The Woman
Warrior: Memoirs of a Girlhood Among
Ghosts (1975). This book described
my life as a Chinese woman living in
predominately white societies and the
balancing of two opposite cultures, the
East and the
West. I strived
to successfully
adapt to, cope
with, function in
and seamlessly
move between
these two distinct
cultures, even
though it became
a juggling act at
times.
I was brought up
in a household that loved Chinese opera,
and it became the vehicle for educating
me about Chinese history, myths and
folktales. At times, it was difficult to
distinguish historical facts from fictional
stories. But that did not matter because
the opera instilled cultural pride and
identity and provided me with a
grounded sense of who I was. The stories
of women warriors included that of Fa
Mu Lan, a legendary Chinese heroine
who impersonates a man and takes her
aging father’s place in battle. Back in
the Han Dynasty, Fa Mu Lan broke
traditional gender roles and excelled in
battle, becoming the first woman general.
July 2013 | Counseling Today | 13
The Disney movie Mulan was based on
Fa Mu Lan.
Kingston wrote, “[My mother] said I
would grow up a wife and a slave, but
she taught me the song of the warrior
woman, Fa Mu Lan. I would have to
grow up a warrior woman.” My parents
also instilled in me the strength of being
a Chinese woman. Fa Mu Lan was
my first Chinese woman role model
who, against all odds, was able to break
traditional gender role expectations.
Armed with Fa Mu Lan’s courage,
Tintin’s sense of adventure, Charlie
Brown’s tenacity, Lao Tsu’s philosophy
and Freire’s creativity, I traveled by myself
halfway around the world to the United
States in 1990. Today, as I work with
immigrants, refugees, and trafficking and
disaster survivors, I provide them with
support as they explore their journeys
and gain a sense of self. At times, this
involves breaking societal and traditional
cultural and gender stereotypes.
The fourth book that influenced me
was Carl Jung’s Man and His Symbols
(1964). The unconscious and the
meaning behind symbols fascinated me.
Coming from a polite culture in which
maintaining face is everything, I learned
that words are secondary to nonverbal
communication. The focus was on
process, the delivery of the message
and the underlying messages, not the
actual content. Jung’s book helped me
understand that
the subconscious
messages
portrayed
through symbols
make a powerful
imprint on our
psyches. As Jung
stated, “The
unconscious,
however, has
taken note of
them, and such
subliminal sense perceptions play a
significant part in our everyday lives.
Without realizing it, they influence
the way in which we react to both
events and people.” Jung described the
complexities of humankind and the
necessity to undergo life challenges: “Life
is a battleground. It always has been,
and always will be; and if it were not
so, existence would come to an end.”
His statement blends with Lao Tsu’s
14 | ct.counseling.org | July 2013
philosophy of the coexisting opposites
and the search for the existential meaning
of life.
Jerome Frank’s Persuasion and
Healing (1961) is the fifth book that
influenced me because it answered
questions I had during my traditional
Western training. For example, individual
counseling skills were emphasized during
my training, but because I came from a
collectivistic, group-orientated culture,
this individual approach appeared
counterintuitive to me. Frank, who
was Irvin Yalom’s teacher, stressed the
importance of group counseling, the
intricacies of group dynamics and the
power of group process. I also questioned
whether some theories were culturally
responsive. According to Frank, when
techniques and
interventions
promote belief
systems and hope,
any theory is as
good as another.
What drew me
to Frank’s work
was his pure
focus on clients.
He examined
the demoralizing
effects on those
who are suffering rather than subscribing
to one theory over another. He
emphasized the commonalities of theories
rather than the exclusiveness of theories
espoused in the profession. His words
rang true to me because what we do in
counseling is to, in essence, encourage
the client to make cognitive, affective and
behavioral changes.
Frank also spoke out against his own
profession of psychiatry, especially as it
related to the use of medication. He was a
pioneer in refusing to accept the medical
model as the only way to construct
mental health. He believed the power
of healing resided in words rather than
drugs. He challenged traditional Western
paradigms and stressed the importance
of a cross-cultural perspective in healing
that involves establishing partnerships
with traditional cultural healers.
Frank was instrumental to my growth
during my training because he showed
the capacity to let go of ego and focus
solely on the client rather than promote
his own agenda. He stayed true to the
healing profession and did not allow
criticism to influence him, reinforcing the
lesson in me to be true to self. In 1995,
I had the honor of having afternoon tea
with Jerome Frank and further discussing
these ideas.
The five books I have selected are
unique, yet they have overlapping themes
that influenced me both personally and
professionally. Each one contributed to
my growth as a counselor. I believe it
is important to be exposed to different
books by different authors and in
different genres. The variety of books I
have chosen speaks to my own diverse
background. u
In Pages of Influence, counselors
discuss the books that have
shaped them professionally,
personally and philosophically.
Send comments about this
article or recommendations
of counselors to feature in this
column to Counseling Today
Editor-in-Chief Jonathan Rollins
at [email protected].
Coming up in the
August issue of
Counseling Today:
u
u
u
u
School counseling
Counseling first
responders
Facilitation strategies
for group counseling
Building trust with
military clients
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© 2013 University of Phoenix, Inc. All rights reserved. | SS-01888A
July 2013 | Counseling Today | 15
Private Practice Strategies - By Anthony Centore
Five reasons why counseling needs a franchise
(and why counselors are ready for it!)
I
n this column in May, I discussed
three reasons why, despite the
proliferation of health care franchises,
a successful counseling franchise has yet to
exist. This month, we’re going to investigate
the issue from the opposite perspective —
why a counseling franchise could work and
how a franchise could benefit both clients
and the counseling industry as a whole.
1) Training, guidance and support
When counselors go into private practice,
the day they open their doors often marks
their first experience owning and running
a business. In fact, some clinicians don’t
realize they have a business at all. I have
heard some counselors say, “I don’t think I
have a business. … I have a practice!”
Counselors love the work of counseling.
They often venture into private practice
because they want to be their own boss,
deliver excellent care and find success
working in their profession at a level
above what other settings have offered.
To this end, a franchise could be an asset
to counselors. A “franchisee” (one who
purchases a franchise) is not an employee
— he or she is a bona fide owner of his
or her own company. At the same time,
a franchisee receives valuable training,
guidance and support from the franchising
company (the “franchisor”).
2) A turnkey business
Even though every counselor is unique,
bringing his or her own style to the
counseling process, many parts of running a
counseling business are the same from one
well-run practice to another. The phone
needs to be answered, the appointments
need to be scheduled, the bills need to be
paid and so on. A franchise could help
counselors because franchisees wouldn’t
need to reinvent the wheel or participate in
costly and time-consuming trial-and-error
endeavors figuring out what works and
what doesn’t. Franchises are designed to
be turnkey businesses, which means they
already have everything one needs to start
16 | ct.counseling.org | July 2013
running the business on day one, including
a proven business model.
In addition, a counseling franchise could
provide additional value if it connected
franchisees with operational services such
as medical credentialing, medical billing,
reception, scheduling, recruiting, electronic
health records and other services. The more
a franchise can take administrative burdens
off the shoulders of counselor-franchisees,
the more those franchisees could focus
on building clinical teams and their first
passion — helping clients.
3) Brand trust and industry standards
Starbucks reinvented the coffee industry
in the United States. Pre-Starbucks (that
is, before 1971), most Americans were
drinking what Howard Schultz, Starbucks’
chair and CEO, describes as “swill” —
coffee made from low-grade robusta coffee
beans instead of higher quality arabica
coffee beans. Many Americans settled for
an inferior brew because they didn’t have
high-quality options and didn’t know
what they were missing. Although small
coffeehouses love to pick on Starbucks for
being too corporate, Starbucks set the bar in
the industry.
Today, few coffeehouses will succeed
by providing a low-quality robusta bean
product. However, coffeehouses that offer a
high-quality alternative to Starbucks coffee
may do exceedingly well. Says Schultz,
“Clearly there’s room for many different
styles of coffee stores or coffeehouses. …
[Customers] decide which coffeehouse
to visit. They may vary their choice of
establishments depending on their need or
mood. In the end, all of us benefit.”
Although many mental health practices
provide excellent care and service, a few bad
apples can spoil the bunch, which has led
to the caricature of the “ditsy therapist,” as
portrayed in movies and the media. Some
people who receive poor clinical care don’t
know they have stumbled upon a subpar
practice. And because no well-known
standard exists to offer an alternative, those
people conclude that counseling is a subpar
profession. A counseling brand could give
clients a benchmark of service and care to
expect, and the industry standard could
serve to help improve the reputation of the
counseling field as a whole.
This is currently happening in the
massage therapy field with the proliferation
of Massage Envy centers. The Massage
Envy franchise is improving the reputation
of massage, and even independent massage
practices will benefit. As with massage
therapy, and even coffee, counseling needs a
brand to set the standard.
4) Community and the family effect
One irony of having a counseling practice
is that even when counselors are in session
with clients all day, counseling can still be
a very lonely job. A counseling franchise
could offer community to private practice
owners, in addition to peer supervision
and support. Such a community could
be unusually strong because, since every
franchisee has a protected trade area (as is
customary with franchises), no franchisee
would be in competition with another.
In fact, the exact opposite would exist.
The success of any franchisee would
benefit the system as a whole. Hence, each
franchisee would have a vested interest in
other franchisees’ successes. This would
provide incentive to counseling franchisees
to openly share their insights and learning
with the community at large.
5) Bargaining and purchasing power
Small mental health practices can struggle
to make ends meet. Being part of a larger
system could lead to increased bargaining
power in areas such as marketing,
technology, recruitment and perhaps even
the ability to negotiate higher rates with
insurance companies.
In addition, it’s reasonable to expect that
a franchise would be better equipped than
a traditional private practice to purchase or
develop valuable resources and technologies.
For instance, developing an electronic
health records program, creating validated
psychological tests, or commissioning an
iPhone or Android app might be outside
the resources of a solo practice. But for a
franchise — a community of practices —
such endeavors could represent another
day’s small investment in the pursuit to
continually expand and improve service
offerings.
Red herrings
When I first began considering whether
a counseling franchise was a viable idea for
our industry, I consulted with a number of
professionals in the field. Many recognized
the value that a franchise could bring, but
several concerns and “what ifs” were also
voiced. For instance:
n What if the franchise didn’t focus on
quality clinical care?
n What if the standardization of practices
took the “soul” out of therapy?
n What if the franchise interfered in the
client-counselor therapeutic relationship?
It became clear that those professionals
who expressed concerns weren’t worried
about a Ritz Carlton- (which uses the
motto “We are Ladies and Gentlemen
Serving Ladies and Gentlemen”) or even
a Starbucks-caliber brand joining the
counseling field. They worried about a
Taco Bell- or McDonald’s-style counseling
franchise harming the field by focusing on
quantity over quality.
It became clear to me that if a franchised
counseling brand were to exist, that brand
would need to be dedicated to excellent
clinical care, clinician creativity, customer
service, and the essence and power of
counseling relationships.
While some worry about what might
happen to the counseling field if a
recognizable brand arises, I tend to worry
about what is going to happen if one does
not. Regardless of which worry you have,
one thing is clear: The time to discuss the
need for a recognizable counseling brand is
now. u
Anthony Centore is the founder
of Thriveworks, a company that
helps counselors get on insurance
panels, find new clients and build
thriving practices. Contact him at
[email protected].
New!
Family Violence:
Explanations and Evidence-Based Clinical Practice
David M. Lawson
“David Lawson has presented a clearly
written, well-organized, and fascinating
review of current treatments for victims
and perpetrators of family violence.
This book will have universal appeal
to students as well as to those already
in practice. The author’s expertise is
noteworthy and this book makes a vital
contribution to the field.”
—Ola Barnett, PhD
Author, Family Violence Across the Lifespan
Distinguished Professor Emerita
Pepperdine University
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July 2013 | Counseling Today | 17
Deconstructing the DSM-5 - By Jason H. King
The DSM-5 does not make diagnoses
I
n the May issue of Counseling
Today, seven counselor educators
and practitioners answered
some pressing questions about the
official release of the fifth edition of
the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5). In this initial
column of what will be a monthly look
at the topic of the DSM-5, I would like
to follow up to offer a deeper level of
understanding about the manual.
Background and history
First, let me introduce myself. I served
as a DSM-5 revision task force committee
member for both the American
Counseling Association and the American
Mental Health Counselors Association.
In these roles, I provided commentary
and feedback on the proposed DSM-5
revisions and copresented with other task
force members at the 2012 ACA and
2012 AMHCA conferences. I will be
presenting with my colleagues again at
the 2013 AMHCA conference in July. In
February, I completed a podcast interview,
“DSM-5 Diagnosis Drill Down,” with
ACA’s Rebecca Daniel-Burke, and I
conducted a webinar with her in June on
the new DSM-5 substance-related and
addictive disorders category.
I also own and direct an outpatient
mental health and substance abuse
treatment clinic (lecutah.com) that
collected data for the American
Psychiatric Association’s (APA) routine
clinical practice field trials that informed
the DSM-5 revision process. For the
past eight years, I have taught DSM
and clinical assessment-based classes at
four universities in three mental health
counseling programs.
OK, enough about me. Let’s talk about
the DSM-5.
18 | ct.counseling.org | July 2013
The DSM-5 revision process began in
1999 (even before the DSM-IV-TR was
published) with preplanning white papers
that addressed a research agenda for the
DSM-5, age and gender considerations
in psychiatric diagnosis, and cultural and
spiritual issues that can affect diagnosis
(for the complete timeline, see dsm5.org/
about/Pages/Timeline.aspx). At that time,
APA’s DSM-5 task force and work groups
began critical discussion and extensive
consumption of the scientific literature
on mental disorders. According to Dr.
John Oldman, a former APA president,
the members of the work groups were not
APA employees, were not paid by APA
and were not under contract with APA.
Their participation was strictly voluntary
and based on their interest in advancing
the field of psychiatry and better serving
patients. The same is true for those,
including me, who participated in the
field trials. Talk about pro bono publico!
On April 16, 2010, Lynn Linde, then
serving as president of ACA, sent a letter
on behalf of ACA to her counterpart at
APA. This letter addressed concerns about
the applicability of the DSM-5 across all
mental health professions, the need to
integrate gender and cultural issues across
disorders and criteria, organization of the
multiaxial system, lowering of diagnostic
thresholds, combining disorders and
dimensional assessments.
In June 2011, K. Dayle Jones, then
chair of the ACA DSM-5 Proposed
Revision Task Force, sent a letter to ACA
Executive Director Richard Yep. Jones
expressed concerns about the prospect
of lowered diagnostic thresholds and
subthreshold disorders, detrimental
consequences, weak empirical evidence,
field trial research design problems and
delays, poor quality of dimensional
assessments, counselors being excluded
and psychotropic medications increasing.
In November 2011, ACA President
Don W. Locke sent a letter to APA
raising concerns about empirical
evidence, dimensional and cross-cutting
assessments, field trials, the proposed new
definition of mental disorder and lack of
transparency. I encourage you to read
Oldman’s scholarly and detailed reply at
dsm5.org/Documents/DOC001.pdf. You
can also read the AMHCA DSM-5 Task
Force’s comments on the draft at amhca.
org/assets/content/DSM5_Task_Force_
ResponsesJune2012.pdf.
Personal cognitive restructuring
I share this brief history of the
counseling profession’s involvement with
the DSM-5 revision process to provide
some historical context of the political
and social advocacy efforts championed
by many of our own. As Paul Peluso,
recent chair of the ACA DSM-5 Proposed
Revision Task Force, stated in the May
Counseling Today article, “We will
see how long it takes to get over this
disorientation.”
With this in mind, I would like to offer
some advice to all counselors who will be
reading, using or otherwise crossing paths
with the DSM-5. That advice is: Engage
in some personal cognitive restructuring.
By this I mean actively identifying
and disputing any automatic irrational
thoughts. Let me offer some examples.
Some counselors may catastrophize
by telling themselves, “The DSM-5
promotes the medicalization of normal
life stressors and encourages people to
use psychotropics instead of counseling
to achieve mental health. I will no longer
have a purpose as a counselor.”
Other counselors may overgeneralize
by thinking, “The DSM-5 lowers the
diagnostic threshold on some disorders.
Therefore, most of my clients will never
be able to overcome their struggles.”
Some counselors may entertain all-ornothing thinking. For example: “APA’s
DSM-5 task force and work groups
did not include counselors, so I do not
need to use this book in my counseling
practice.”
Mental filter may be displayed in some
counselors who think, “The DSM-5
field trials were rushed and unreliable.
Therefore, the entire book is flawed.”
Other counselors may jump to
conclusions by telling themselves, “Moneydriven pharmaceutical companies
influenced the DSM-5 revision process.”
Finally, some counselors may
experience magnification by claiming,
“The DSM-5 revision process was sloppy,
rushed and biased.”
My suggestion to counselors of
all specialties is to brush up on their
cognitive disputation skills as proposed by
Albert Ellis and Aaron Beck. The DSM-5
is here, and it is not the end of the world.
Critical perspectives and responses
I’d like to offer a few of my own critical
perspectives and responses to some of the
comments my colleagues made in the
May Counseling Today. Namely that “a
general loosening of diagnostic thresholds”
means more people will meet criteria
for mental disorders, and the reduced
requirements needed for diagnosis may
cause counselors to “blur the boundary
between normality and pathology.”
It is important that we do not globalize
these statements because it depends on
which disorders are being addressed —
and in their full context. The diagnostic
criteria for elimination disorders and
personality disorders have not changed
from the DSM-IV-TR criteria, and
criteria to diagnose paraphilic disorders
have not been altered, although some
important conceptual reformulations
have been made. Regarding disruptive
behavior diagnoses (conduct disorder
and oppositional defiant disorder), APA
work group chair Dr. David Shaffer
said changes to the criteria are designed
to make the criteria considerably more
specific than DSM-IV-TR criteria. He also
said the changes are expected to decrease
prevalence of the diagnosis. Specifically,
“the criteria for oppositional defiant
disorder indicate that symptoms must
be present more than once a week to
distinguish the diagnosis from symptoms
common to normally developing children
and adolescents.”
To improve precision regarding
duration and severity and to reduce
the likelihood of overdiagnosis, all of
the DSM-5 sexual dysfunctions, except
substance- or medication-induced sexual
dysfunction, now require a minimum
duration of approximately six months.
Regarding the new diagnosis of gender
dysphoria for children, Criterion A1 (“a
strong desire to be of the other gender
or an insistence that he or she is the
other gender”) is now necessary but not
sufficient to meet the diagnosis, which
makes the diagnosis more restrictive and
conservative. According to Jack Drescher,
a member of the DSM-5 work group
on sexual and gender identity disorders,
“It’s really a narrowing of the criteria
because you have to want the diagnosis.
It takes psychiatrists out of the business
of labeling children or others simply
because they show gender-atypical
behavior.” Moreover, criteria for the new
category emphasize the phenomenon of
“gender incongruence” rather than crossgender identification, as was the case in
the DSM-IV-TR. By separating gender
dysphoria from sexual dysfunctions and
paraphilias (with which it had previously
been included in the DSM-IV-TR in a
chapter titled “Sex and Gender Identity
Disorders”), work group members said
they hope to diminish stigma attached
to a unique diagnosis that is used by
mental health professionals but for which
treatment often involves endocrinologists,
surgeons and other professionals.
In a discussion about the new diagnosis
of avoidant/restrictive food intake
disorder, Timothy Walsh, chair of the
DSM-5 eating disorders work group,
commented: “We have good data to
indicate that if the criteria are rigorously
applied by people familiar with the
syndrome, only a relatively small number
of people will meet the criteria. The
lifetime prevalence of the disorder, we
believe, is less than 5 percent, and we
have good data that individuals who meet
the criteria have a significantly higher
frequency of anxiety and depression.”
Two new diagnoses — REM sleep
behavior disorder and restless legs
syndrome — have been added, which
should significantly reduce the use of sleep
disorder–not otherwise specified. The
criteria for insomnia include a frequency
threshold of three nights per week and
duration of at least three months. The
DSM-5 text also includes dimensional
measures of severity.
July 2013 | Counseling Today | 19
For posttraumatic stress disorder
(PTSD), there are now four symptom
clusters in the DSM-5 (as opposed
to three in the DSM-IV-TR): reexperiencing, avoidance, persistent
negative alterations in mood and
cognition, and arousal. In the DSM-5,
PTSD is now developmentally sensitive.
Diagnostic thresholds have been lowered
and criteria modified for children 6
and younger. Criteria for both acute
stress disorder and PTSD are now more
explicit concerning how the distressing or
traumatic event was experienced: directly,
witnessed or indirectly. The DSM-5 work
group members believe the changes to
the PTSD criteria are unlikely to affect
epidemiology of the disorder, but if
there is any effect, it will be to lower the
prevalence slightly.
To be diagnosed with a substance
abuse disorder in the DSM-IV-TR,
individuals needed to present with only
one criterion, whereas individuals must
present with a minimum of two criteria
to be diagnosed with a substance-related
disorder in the DSM-5. And to avoid
overdiagnosing substance abuse solely on
legal involvement (as happened with the
DSM-IV-TR), the DSM-5 replaced this
criterion with craving.
In diagnosing schizophrenia, counselors
will notice an important conceptual
change from the DSM-IV-TR. An
individual can no longer meet Criterion
A for psychosis with a single bizarre
delusion, but must have a minimum of
two symptoms — one of which must be
one of the core psychotic symptoms of
“delusions, hallucinations or disorganized
thinking.” Regarding the diagnosis of
intellectual disability (formerly “mental
retardation” in the DSM-IV-TR), the
DSM-5 criteria mark a move away from
relying exclusively on IQ scores and toward
using additional measures of adaptive
functioning. DSM-IV-TR criteria
had required an IQ score of 70 as the
cutoff for diagnosis. The new criteria
recommend IQ testing and describe
“deficits in adaptive functioning that
result in failure to meet developmental
and sociocultural standards for personal
independence and social responsibility.”
The ninth chapter of the DSM-5
eliminates several diagnoses (somatization
disorder, hypochondriasis, pain disorder
and undifferentiated somatoform
20 | ct.counseling.org | July 2013
disorder), removes some redundancies
and extraneous features in previous
criteria, and more clearly delineates the
separate diagnoses that make up this
chapter. To be diagnosed with somatic
symptom disorder, the individual must
be persistently symptomatic for at
least six months, ruling out random or
intermittent symptom presentations. To
diagnose bipolar-related disorders in the
DSM-5, counselors must properly assess
for and actively include an individual’s
activity and energy level, in addition
to the classic heightened and elevated
mood symptom used in the DSM-IVTR. This diagnostic modification will
lead to a reduction in the misdiagnosis
of bipolar disorder in adolescents and
adults, and challenges counselors to
be more systematic in their diagnostic
formulation. The new diagnosis
of disruptive mood dysregulation
disorder should significantly reduce
the overdiagnosis of bipolar disorder in
children, and the associated overuse of
antipsychotic medications, that occurred
with the DSM-IV-TR.
The DSM-5 contains the newly
modified autism spectrum disorder
(considered a neurodevelopmental
disorder). The diagnostic criteria were
collapsed into two core symptoms, with
one of the two containing two symptoms
that must be met: deficits in social
communication and social interaction
(so, essentially, still three symptoms).
The DSM-5 criteria were tested in reallife clinical settings as part of the field
trials, and analysis from that testing
indicated there will be no significant
changes in the prevalence of autism
spectrum disorder. More recently, the
largest and most up-to-date study,
published by Marisela Huerta et al. in
the October 2012 issue of The American
Journal of Psychiatry, provided the most
comprehensive assessment of the DSM5 criteria for autism spectrum disorder
based on symptom extraction from
previously collected data. The study
found that DSM-5 criteria identified 91
percent of children with clinical DSMIV-TR pervasive developmental disorder
diagnoses. The remaining 9 percent
will be properly diagnosed as having a
communication disorder, reducing the
misdiagnosis of autism spectrum disorder.
With the DSM-5, several of an
individual’s attention-deficit/hyperactivity
disorder symptoms must be present
prior to age 12, as compared with age
7 in the DSM-IV-TR. However, this
change is supported by substantial
research published since 1994 that found
no clinical differences between children
identified by age 7 versus later in life in
terms of course, severity, outcome or
treatment response. Regarding depressive
disorders, the DSM-5 aims to provide
an accurate diagnosis for people who
need professional help and no diagnosis
for those who do not. Therefore, several
strategies are provided to help clinicians
using the DSM-5 to differentiate major
depression, “normal” bereavement and
pathological bereavement, including
changes in diagnostic criteria as well as in
the text.
It is true that diagnostic criteria for
binge eating disorder in the DSM-5
reduce from twice per week to once per
week for recurring episodes of eating
significantly more food in a short period
of time than most people would eat
under similar circumstances. These
episodes should also be marked by feeling
a lack of control.
The new DSM-5 diagnosis of mild
or moderate neurocognitive disorder
(dementia) reflects an attempt to
move upstream toward identifying
and diagnosing Alzheimer’s and other
neurocognitive disorders earlier.
For acute stress disorder, previous
DSM-IV-TR criteria requiring dissociative
symptoms were too restrictive.
Individuals can meet DSM-5 diagnostic
criteria for acute stress disorder if they
exhibit any nine of 14 listed symptoms
in these categories: intrusion, negative
mood, dissociation, avoidance and
arousal. Yet these criterion reductions
do not necessarily mean that rates of
individuals qualifying for these diagnoses
will increase as long as counselors balance
this out with a focus on the entire person.
Now what?
In the DSM-5, the multiaxial system
of previous editions is eliminated, and
chapters are now arranged according to
a life span or developmental approach
(which fits the paradigm of counseling).
Disorders affecting children appear
first, and those more common in older
individuals appear later. The intention
throughout is to group disorders that
are similar to one another across a range
of validators, including symptoms,
neurobiological substrates, familiarity,
course of illness and treatment response.
With all of these changes, it is
imperative that counselors remember
this mantra: The DSM-5 does not make
diagnoses; counselors, systematically
and objectively using standardized and
nonstandardized testing, specialized
clinical assessment techniques and case
conceptualization procedures, make
diagnoses that are developmentally
and culturally sensitive. Let me repeat:
Counselors make diagnoses, not the DSM-5!
I love these words from the DSMIV-TR: “The specific diagnostic criteria
included in the DSM-IV are meant
to serve as guidelines to be informed by
clinical judgment and are not meant to
be used in a cookbook fashion” (emphasis
added). Furthermore, “a common
misconception is that a classification of
mental disorders classifies people, when
actually what are being classified are
disorders that people have.”
With these words, let’s embrace the
DSM-5 and properly use it as one of our
many social change tools to promote
growth, development and wellness in
our clients. As we take this journey, I
welcome requests for DSM-5 topics you
would like to see addressed in upcoming
issues of Counseling Today. My email
address can be found below. Talk to you
next month! u
Jason H. King is core faculty in the
CACREP-accredited mental health
counseling program at Walden
University. He is a state-licensed
and national board certified
clinical mental health counselor
and an AMHCA diplomate and
clinical mental health specialist
in substance abuse and cooccurring disorders counseling.
He received the 2012 AMHCA
Mental Health Counselor of the
Year Award. Contact him at jking@
mellivoragroup.com.
Letters to the editor:
[email protected]
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22 | ct.counseling.org | July 2013
Risk Management for Counselors - By Anne Marie “Nancy” Wheeler
How to explain (and understand) HIPAA
Question: I am a licensed counselor
in private practice, and I am considered
a HIPAA “covered entity.” I’d like to
fully explain the myriad privacy rights
to my clients and also want to be fully
compliant with the law. Can you give
me some up-to-date, understandable
resources on HIPAA?
Answer: You’re in luck! The U.S.
Department of Health and Human
Services Office for Civil Rights has
recently published a variety of tools
to help both providers and consumers
navigate the murky waters of privacy
and security related to the Health
Insurance Portability and Accountability
Act (HIPAA). First, the Office for Civil
Rights has developed consumer guides,
or fact sheets, which are available in eight
languages (see hhs.gov/ocr/privacy/hipaa/
understanding/consumers/). The fact sheets
are accompanied by videos posted on
YouTube. Another video that explains
basics of the HIPAA security rule for
providers in small practices is also posted
(see youtube.com/user/USGovHHSOCR).
Furthermore, the Office for Civil
Rights has produced three programs in
conjunction with Medscape, available at
no cost to providers, on compliance with
the HIPAA privacy and security rules.
n The first is called “Patient Privacy:
A Guide for Providers” (see medscape.org/
viewarticle/781892?src=ocr).
n The second is “HIPAA and You:
Building a Culture of Compliance”
(medscape.org/viewarticle/762170?src=ocr).
n The third is called “Examining
Compliance with the HIPAA
Privacy Rule” (medscape.org/
viewarticle/763251?src=ocr).
The availability of simple,
understandable resources is good news
for counselors and other mental health
providers who work in small private
practices. Not only can counselors
educate themselves and their clients on
changing HIPAA obligations, but also
counselors may find these tools useful
in conducting mandatory workforce
training if they employ therapists or
administrative staff.
One more hint: Don’t forget that
many states have their own privacy laws
that should be consulted in addition to
federal law.
purposes only. For specific legal advice,
consult your own local attorney. To access
additional risk management Q&As, go to
counseling.org/knowledge-center/ethics and
scroll to the bottom of the page
for the ACA members-only link to
the Risk Management Section of the
ACA website. u
Anne Marie “Nancy” Wheeler, J.D.,
a licensed attorney, is the risk
management consultant for the
ACA Ethics Department.
u
The question addressed in this column
was developed from a de-identified
composite of calls made to the Risk
Management Helpline sponsored by the
American Counseling Association. This
information is presented for educational
Letters to the editor:
[email protected]
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July 2013 | Counseling Today | 23
Through a Glass Darkly - By Shannon Hodges
The change I wish to see in the (counselor’s) world
T
he explosion shattered the
exuberance and excitement
with its concussive waves
of force, sound, confusion and terror.
Limbs were blown off and shards of glass
shredded skin. Suddenly, there were
much more serious concerns than caring
for muscles still fatigued from running
over 26 miles. As the acrid smoke cleared,
havoc and panic were omnipresent.
The terrorist attack in April near the
finish line of the Boston Marathon
shook the country and a good deal of
the world. Countless people wondered
how anyone could be so callous as to
detonate bombs intended to kill or maim
so many innocent people, including
8-year-old Martin Richard, killed as he
lingered near the finish line. Quickly, the
country rallied around the victims, family
members and first responders.
The question of “Why?” rears its
hideous head. Few good answers are to
be found amid such capricious violence.
Certainly the “answer” is well beyond
this author’s grasp. Like any writer,
however, I find it cathartic to offer
my meditations on such tragic events.
Weighing in prosaically may represent the
literary equivalent of sticking my hand
into a hornet’s nest. Sometimes, however,
it’s necessary to risk ridicule. I believe
part of the solution to extreme violence
lies somewhere beyond retribution.
Furthermore, we need to take a wideangle view and examine the systemic
conditions that create the fertile breeding
grounds for extremism.
During the aftermath of such hatefueled tragedies, I am curiously reminded
of Elisabeth Kübler-Ross’ stages of
grief. These “stages” might better be
termed “phases” because those who are
grieving tend to vacillate from one stage
to another. Regardless, my anecdotal
24 | ct.counseling.org | July 2013
observation is that after such events,
we generally witness a brief period of
shock, which is followed by rage, then
the scapegoating of people who “look
like terrorists” (code for anyone who
is culturally different), then speeches
by various and sundry opportunistic
politicians and, finally, real grief for the
victims and their loved ones. Finally,
we are left grappling with troublesome
questions that lack satisfactory answers.
Hate: My personal history
As a child growing up in the South of
the 1960s and 1970s, I caught the tail
end of the civil rights era. Martin Luther
King Jr. exemplified stoic passivism in
the face of violence. I recall lynchings,
beatings and disturbing TV images
of white cops attacking black people
simply because they were marching —
peacefully — for the right to vote, send
their children to better schools and
live without fear of harassment, assault
and murder. Ironically, this sanctioned
violence was occurring in a country that
boasted of its freedom. This disconnect
between civics class idealism and
graphic realism was far too complex and
confusing for my grade-school mind
to assimilate. But I was profoundly
disturbed by images of visceral anger,
violence and hatred etched on the faces of
fellow whites.
In church, we studied Jesus of
Nazareth, as chronicled in the synoptic
Gospels of the New Testament. Although
I was fed a steady diet of Christology,
for me the historical figure that
emerged from the texts was a radical,
itinerant, “rabbi”-pacifist who railed
against politicians, wealthy people and
religious leaders living off the backs
of the impoverished. Sadly, Jesus’
message of social justice and passivism
has been so papered over by orthodox
Christianity that otherwise intelligent
people, religious and secular, often miss
it. Indigenous Australian musician Kev
Carmody’s “Comrade Jesus Christ” is, in
my opinion, the best poem of reference.
I’ve never understood how a leader who
said “love your enemies,” “turn the other
cheek” and “pray for those who persecute
you” could spawn followers so easily
inflamed against those they fear. Thus,
contrary to the vulpine media, religious
violence is not limited to one particular
religious movement in the Middle East.
The change we wish to see
During college, I was influenced by
Mahatma Gandhi. My favorite Gandhi
quote is, “We must be the change we
wish to see in the world.” As with Jesus’
message two millennia earlier, such
radical, peaceful change seems neigh
impossible in a world chock-full of saberrattling messages exhorting violence.
Gandhi-esque transformation requires
intense self-reflection. For example, our
very nation holds the distinction of being
the Western world leader in homicides.
The past 15-plus years have witnessed a
depressing litany of violent episodes —
Oklahoma City, Columbine, Virginia
Tech and, most recently, Sandy Hook, to
cite just a few. Although it is not popular
to admit, our society is inundated with
far more violence from within than from
extremists from the outside, though
foreign extremists do pose a threat.
In a thought-provoking essay, Thomas
Merton wrote that “the root of war is
fear” and advised that the way back to
sanity is to recognize the potential good
and evil in everyone. Fortunately, many
individuals are actively promoting civil
engagement. Eboo Patel, a Muslim son
of Indian immigrants, has founded
a grass-roots organization, Interfaith
Youth Core, that trains college
students in techniques for learning
about religious differences and finding
common ground despite cultural and
faith differences. His informative book,
Acts of Faith, and its follow-up, Sacred
Ground, are recommended reading
for everyone, regardless of spiritual or
secular orientation. In a talk at Yale
University, Patel asserted that the counter
to religious messages of violence and
martyrdom should be more engagement
regarding religion, not avoidance of it.
Furthermore, he notes that some of the
20th century’s greatest leaders — the
aforementioned King and Gandhi —
constructed coalitions with people of
other faiths precisely because of their
respective faith systems, not despite them.
Patel asserts that only when we offer role
models of religious and cultural respect
and tolerance can we hope to effectively
combat the violent rhetoric of religious
fundamentalists.
Naturally, many intellectuals,
politicians and religious leaders will view
Patel as misguided at best, horribly naive
at worst. In fairness, the same has been
said of Gandhi, MLK, the Dalai Lama,
Mother Teresa and others. We have to ask
why hate messengers seem to be taken so
much more seriously by the media and
populace. Peacemaking sells less. Jesus’
Sermon on the Mount (“Blessed are the
peacemakers”), Rumi’s transcendent
verse, and Gandhi’s and MLK’s populism
are exceptions, representing outliers in
a vast bell-shaped curve of historical
violence. In fact, peaceful voices are easily
drowned out by enthusiastic shouts of
anger. Pacifist messengers such as John
Lennon are harassed and often murdered.
Peacemakers such as former President
Jimmy Carter are often labeled as weak
and discounted.
What is the role of counselors?
In an early article for this column,
I advocated that all schools employ
counselors to teach life skills classes
beginning in first grade. Psychologist
and science journalist Daniel Goleman
believes that emotional intelligence is
more important for success than a high
IQ. I second his motion. Skills such
as dispute resolution are as important
as SAT scores and possibly more so,
given that grads of elite institutions
have sometimes led us into ill-conceived
wars that risked few of their own family
members.
Tikkun olam is a Hebrew phrase
meaning “to repair the earth.” Peaceful
resolution of disputes would seem to
fall under such earthly “repair.” Waging
peace is a grass-roots responsibility and
should be part of a counselor’s ethical
responsibility. Many counselors do, in
fact, have mediation as part of their
job description, although this is the
exception and scarcely the rule. We as
counselors are the perfect profession to
serve as mediators in schools, colleges,
government and perhaps in venerable
organizations such as the United
Nations. In fact, while delivering a series
of workshops at the U.N.-chartered
University for Peace in Costa Rica, my
spouse and I suggested the institution
start a counseling program that would
focus on mediating disputes between
warring gangs, religious factions and
countries. As a longtime counselor
educator, I have spent countless hours
educating students about counseling,
assessment and interviewing, but little
in the way of how to mediate conflicts.
As the counseling profession strengthens
within the United States and beyond,
perhaps peaceful reconciliation might
become a serious focus for our profession,
maybe as another foundation of social
justice.
It is clear to me that guns and
bombs bring about only more guns
and bombs. A more adaptive strategy
in schools, colleges, neighborhoods
and developing countries is needed.
It must be acknowledged that societal
inequities will always exist, making some
level of continued violence a certainty.
Carl Rogers was a leader in the peace
movement of the 1960s and believed in a
more constructive approach to resolving
violence, both on a micro and macro
level. Counselors certainly can work
on the micro level (in schools, colleges,
communities and so on) and pressure
legislative bodies to seek more just,
equitable solutions on a national level.
Regarding terrorist acts such as 9/11 and
the Boston Marathon bombing, and
national tragedies such as Sandy Hook,
our resources should be focused on
creating a more just society.
A commitment to change
This column could be criticized
as being overly optimistic regarding
professional influence. But if we as
counselors are not proactive, optimistic
and socially engaged as professionals,
I have to wonder about our relevance.
Although it is easy to write off individual
and organizational influence with the
old saw “We’re just one group,” consider
Margaret Mead’s famous statement:
“Never doubt that a small group of
thoughtful, committed citizens can
change the world. Indeed, it is the only
thing that ever has.” At more than
53,000 members, our association is
no longer small. I also believe we can
effect significant change provided we are
committed.
I have no satisfying answers for the
gross violence exemplified in Boston. But
I do believe socially just actions likely
represent the best option for lessening
such extremism. I think the eremitical
Merton nailed it when he wrote, “To
some men, peace merely means the
liberty to exploit other people without
fear of retaliation or interference.”
Real peace involves justice. Given that
social justice is a significant part of the
ACA Code of Ethics, peaceful resolution
of conflicts — whether local, national
or global — must also become part of
our mission. Healing the earth will be
accomplished one client at a time. u
Shannon Hodges is a licensed
mental health counselor and
associate professor of counseling
at Niagara University. Contact him
at [email protected].
Letters to the editor:
[email protected]
July 2013 | Counseling Today | 25
New Perspectives - By Julia Whisenhunt
Making room for creativity: Learning how to
therapeutically engage clients in the creative process
“A
ll work and no play makes Jack
a dull boy.” It seems that
adage applies not only in the
business world but also in our counseling
work with clients. This month, Julia
Whisenhunt talks about her effective use
of creativity in the counseling setting.
Whisenhunt, a licensed professional
counselor, earned her doctorate in
counseling education and practice from
Georgia State University in 2012. She
currently works as a professor at the
University of West Georgia.
u
I should begin by saying that most of
what is covered in this article is not novel.
Wise authors before me have discussed
the therapeutic benefits of expressive
therapy. They have educated counselors
to effectively and appropriately use
expressive interventions with a variety
of clients. Indeed, the information
contained herein is well established.
However, my personal experience is
unique. Through sharing my journey,
I hope to inspire others to explore the
power of creativity as a therapeutic tool.
The first time I was challenged as an
adult to acknowledge my creativity was
during a master’s-level “Explorations Into
Creativity” psychology course. The true
reason I enrolled in the class was because
I admired the professor, certainly not
because I saw myself as a creative person
or having any significant creative ability.
That course changed my life. During
a single semester, I was challenged to
redefine my definition of creativity and
to see that creativity is not equivalent to
artistic ability. To be sure, I lack in the
26 | ct.counseling.org | July 2013
latter. I have come to find, though, that
creativity is a way of thinking. It is a
process of looking at the world through
unconventional lenses.
Since my master’s program, I have
been on a path toward actualizing my
creative potential as a professional
counselor. When I first began using
creative interventions in my volunteer
work with an adult group, I met clear
resistance. I often heard responses such as
“I haven’t done this since kindergarten”
or “This is the kind of thing my kids
do.” It was apparent that adults might
not automatically appreciate the value of
creativity nor understand its therapeutic
functions. I reminded them that there
is no right or wrong way to be creative
and encouraged them to give it a try to
see what would happen. Very quickly,
clients found themselves in what Mihaly
Csikszentmihalyi calls flow.
In the book Creativity: Flow and the
Psychology of Discovery and Invention,
Csikszentmihalyi defines flow as a state
of intense focus and oneness with the
creation. The clients became so engaged
in the process that they stopped talking
about their anxieties and began to
visibly relax. They must have realized the
transformation as well.
For the past six years, a climate of
acceptance and excitement for creativity
has flourished in that program. Despite
the occasional self-criticism of “I’m not
creative,” I am rarely confronted with
resistance. Instead, I have noticed that
existing clients talk with new clients
about our creative interventions and
demonstrate an appreciation for the
power of creativity. It is no longer a rare
occurrence to hear comments such as,
“Wow, I feel so relaxed” after engaging in
a creative intervention or “Now I see why
we do that [use creativity in counseling].”
Clients talk about how they express
themselves differently through creativity
and how their anxiety seems to melt away.
They talk about how they learn about
themselves through creative interventions.
And sometimes, they don’t say a word.
I don’t think it is always important to
talk about the creative process. For some,
the process itself is what is inherently
therapeutic, and it doesn’t require
discussion or intellectualization.
My volunteer work with the group
transformed me in ways I couldn’t have
previously imagined, empowering me
to use creativity with adolescents and
in individual counseling with adults.
I’ve witnessed the power of creativity as
a meaningful therapeutic tool and can
no longer imagine being a professional
counselor without it.
My path toward effective use of
creativity in counseling has included
many lessons, taught to me by my clients
and by experts in the field such as Cathy
Malchiodi and Samuel Gladding. My
goal is to share with you some of the most
meaningful lessons from my experience.
Perhaps the appropriate place to start is
with professional orientation.
Lesson 1: Be intentional. It was clear
to me from the beginning that there is a
difference between making therapeutic
use of creativity and doing crafts with
clients. I try to find interventions that
have a clear therapeutic objective,
although I know the outcome may be
different for each client. In my view,
this process of matching interventions
to client needs is absolutely essential to
effective practice. We use intentionality in
verbal interventions with clients. It seems
common sense that the same principle
would apply to creative interventions.
Lesson 2: Be encouraging. Another
important lesson, touched on earlier,
is learning how to manage client selfcriticism. Clients often berate their own
artistic and creative efforts. My role is
to assure them that we are all creative in
our own unique ways and that they are
not being evaluated for their artistic or
creative abilities. Regardless of my efforts
to allay their anxieties, clients often have
a sense of self-evaluation that can get in
the way.
One way I’ve minimized this is through
the use of encouragement. I’ve learned
how to encourage clients instead of
praising them. In session, I do not tell
clients how beautiful their artwork is or
that they have a brilliant idea. Instead,
I focus on the effort and intentionality
they put into their creations. Sometimes,
clients will directly ask me to praise
them. I don’t. Instead, I say something
like, “You worked really hard on that”
or “You put a lot of thought into that”
or “I can see you’re proud of what you’ve
created.” I find that by encouraging
them, they get what they need and they
learn to encourage themselves. They also
learn to rely less on others for praise and
validation of their creativity, which often
extends into other areas of their life
as well.
Lesson 3: Be flexible. Another
valuable lesson I’ve learned is the power
of flexibility. Although clients may not
always engage in an intervention the
way I envision the process, they engage
in the ways they need at that moment in
their life. Sometimes, I may misjudge
their readiness to process a feeling or
experience. Other times, they assert their
needs by modifying the intervention.
It is less important to me that clients
engage in the intervention according to
some plan that I have developed. It is
most important that they experience a
therapeutic outcome — whether that is
relaxation, catharsis or insight — as a
result of our time together.
Lesson 4: Be open to growth.
The fourth and final lesson is perhaps
the most important that I’ve learned
through the process, both personally
and professionally. That lesson is: I am
in a constant state of growth. As I learn
how to more effectively use creative
interventions to meet clients’ unique
needs, I grow and change, both as a
counselor and a person. Creativity has
changed not only my clients’ lives, but
also my own. u
Contact column editor
Donjanea Fletcher Williams at
[email protected].
Letters to the editor:
[email protected]
My life, my story
Nominate an exceptional student or new professional to be featured in “My life, my
story” by emailing [email protected].
This month, master’s
student Gina Alderman
is featured as the recent
founder of the Alpha
Delta Chi Chapter of Chi
Sigma Iota.
Age: 51
Home/current
residence: Norfolk, Va.
Education: Currently
pursuing her M.A. in
professional counseling
at South University, Virginia Beach campus; M.S. in management from Troy State
University and B.S. in health care management from Park University
Greatest professional accomplishments: Completing 28 years of active-duty
service as a health care administrator in August 2011. I retired as a commander
from the U.S. Navy Medical Service Corps. I also founded the Alpha Delta Chi
Chapter of Chi Sigma Iota international counseling honor society on my campus
in December 2012.
Biggest professional challenge: Participating in an international medical
planning team to bring surgical and mental health trauma teams and MRI
diagnostic technologies to U.S. military forces in Kandahar and Bastion,
Afghanistan, in 2009 through 2011. I also served as the lead medical planner,
collaborated and planned the mental health care for 32,000 Cuban and Haitian
migrants in Guantanamo Bay, Cuba, between 1994 and 1995.
Words of advice for new professionals and students: Follow your passion.
I have desired to serve others and be a member of the counseling profession for
more than 10 years. No matter how old you are, it’s never too late to continue your
education and reach out to others.
July 2013 | Counseling Today | 27
Counselor Career Stories - Interview by Danielle Irving
From athlete to counselor:
A sports counselor’s story
I
recently had the pleasure of
speaking with Joseph Stanley, an
American Counseling Association
member and experienced sports
counselor. I was immediately intrigued
by his interest in discussing the field of
sports counseling as well as the benefits it
provides. This is his story.
Danielle Irving: What sparked your
initial interest in sports counseling?
Joseph Stanley: Throughout
high school, I had a strong interest
in psychology and a yearning for
competitive sports. After I graduated
from college with a B.A. in psychology,
my future was uncertain. However, I did
know that I wanted to pursue something
in sports [because] I missed the
connection I had with competitive sports.
As a former high school and collegiate
athlete, I wanted to create a niche where
I could incorporate both my passion for
sports and psychology.
Initially, I sought the strength and
conditioning profession, but it neglected
the psychological aspects of sport. An
opportunity presented itself to where I
was able to pursue a sports psychology
and counseling career route, so I jumped
at the chance and it has been the most
rewarding journey ever since.
DI: What does sports counseling
entail?
JS: The profession requires a graduate
education, experience counseling athletes,
certification through the Association for
Applied Sport Psychology and a state
license. It requires a thorough knowledge
of psychological and counseling theory,
various sports and their contexts,
kinesiology, social psychology and
multicultural issues, to name a few.
A typical day in the life of a sports
counselor might include counseling
athletes, attending practices or games,
conducting workshops and attending
28 | ct.counseling.org | July 2013
meetings with coaches. It is definitely not
your usual 9-to-5 career.
DI: Please share your education, any
specific certifications or licenses, and
even memberships to associations and
organizations that relate to your career.
JS: Besides my B.A. in psychology, I
hold master’s degrees in kinesiology and
professional counseling. In addition, I
have a post-master’s certificate in sports
psychology. I am a certified consultant
through the Association for Applied
Sport Psychology (AASP), a certified
strength and conditioning specialist
through the National Strength and
Conditioning Association (NSCA) and
a licensed professional counselor in
the state of Missouri. Currently, I hold
memberships in ACA, AASP, NSCA
and American Psychological Association
Division 47: Exercise and Sport
Psychology.
DI: For individuals who may be
interested, what is required to practice
sports counseling? JS: This is a great question and one that
students often ask. There are different
paths that one can take depending on
your desire to seek advanced knowledge,
experience, certification and licensure.
There is no associated state license with
sport psychology. Thus, one would have
to choose to seek licensure as either a
psychologist or a counselor.
Obviously, a doctorate or master’s
degree must merit consideration. Further,
one would need to obtain certification
through AASP, which has its own specific
educational and internship requirements.
This certification merits high recognition
in the sport psychology field. In fact,
one must possess it in order to qualify
for the USOC (United States Olympic
Committee) Sport Psychology Registry.
One can work with athletes with just a
doctorate or master’s in sport psychology
Joseph Stanley
without a license or certification.
However, your services are ethically and
legally restricted because you do not
hold a license or certification. My advice
would be to seek licensure first, then
add sport psychology and certification
as an adjunct. Obtainment of advanced
education, experience, certification
and licensure will strengthen one’s
sport psychology expertise, increase
marketability and advance one’s career.
DI: What type of clients do you serve?
What would their reason be for reaching
out for your services?
JS: The majority of my time revolves
around counseling NCAA Division I and
Division II athletes through individual
counseling sessions. Secondarily, I
conduct sport psychology workshops for
teams and, oftentimes, counsel coaches
individually or to offer suggestions
about leadership, motivation and
communication practices. I counsel
student-athletes for issues specifically
related to their sport as well as for issues
that non-student-athletes struggle with
throughout their academic years.
DI: Do you utilize a particular theory
to assist your clients?
JS: Like most counselors, I hail from
a foundation of the theoretical classics
and adopt some that are more akin to
third-wave theories. Freudian, Jungian,
Rogerian, Adlerian, Gestalt, existentialism
and phenomenology pepper my
foundation. Currently, I utilize theoretical
aspects from acceptance and commitment
theory (ACT), relational frame theory
(RFT), some solution-focused theory
and, of course, cognitive behavioral
theory.
DI: Do you see that some theories
are more effective than others with this
population?
JS: Absolutely. Third-wave theories,
such as ACT and RFT, are exceptionally
effective. As empirical-based theories,
these theories have gained sound research
support with athletic populations
and have continued to expand as
new outcomes emerge about their
effectiveness.
DI: We have more than 53,000
members in ACA. Is there anything else
you want our members to know about
you?
JS: The field is exceptionally
rewarding, especially when the athletes
you have counseled excel not only
in their sport, but also in their lives
outside of sport. The sports counseling
field should continue to grow, but it
requires a diligent, persistent effort to
educate others about the profession,
to market yourself and the profession,
and to continue along the journey of
development, evolution and resolution
within the field and life.
I do have two websites for more
information: lindenwoodlions.com/
sports/2009/7/7/sportscounseling.aspx and
gridironperformance.com. As a side note,
I hope to establish a sports counseling
division within ACA sometime in the
near future if enough interest is generated
to meet the specific requirements for
division acceptance. u
Danielle Irving is the project
coordinator for ACA’s professional
projects and career services
department. Contact her at
[email protected].
Letters to the editor:
[email protected]
New Edition!
Assessment in Counseling:
A Guide to the Use of Psychological
Assessment Procedures, Fifth Edition
Danica G. Hays
“Danica Hays has thoroughly
updated and broadened this textbook,
which we authored through the first
four editions. We are confident that
this will remain a widely used text for
graduate courses and wholeheartedly
endorse this revision.”
—Albert B. Hood, EdD and
Richard W. Johnson, PhD
Now more user-friendly than
ever, while continuing the legacy
of excellence that Albert Hood
and Richard Johnson began,
the latest version of this best-selling text updates students
and practitioners on the basic principles of psychological
assessment and the most widely used tests relevant to
counseling practice today. Hays makes assessment highly
accessible as she walks the reader through every stage of
the process and provides practical tools such as bolded
key terminology; chapter pretests, summaries, and review
questions; self-development and reflection activities; client case
examples; practitioner perspectives illustrating assessment in
action; and handy tip sheets.
More than 100 assessment instruments examining
intelligence, academic aptitude and achievement, career and
life planning, personal interests and values, personality, and
interpersonal relationships are described. Also discussed are
specialized mental health assessments for substance abuse,
depression, anxiety, anger, self-injury, eating disorders, suicide
risk, and attention deficit hyperactivity disorder.
2013 | 400 pgs | Order #78074 | ISBN 978-1-55620-318-3
List Price: $72.95 | ACA Member Price: $49.95
Order Online: counseling.org
By Phone: 800-422-2648 x222
(M-F 8am–6pm)
July 2013 | Counseling Today | 29
Body language
By Lynne Shallcross
Even if counselors don’t specialize in eating disorders and body image,
statistics show they need to embrace their roles in preventing, detecting
and treating these issues that stretch across racial, cultural, gender and age lines
{
clients who struggle with those issues.
Even if eating disorders aren’t a counselor’s
specialty, it may be in the client’s best
interest in certain cases for the counselor to
work with that client, says Margo Maine,
a clinical psychologist who has specialized
in eating disorders and
related issues for more
than 30 years. “You may
not be experienced in
eating disorders, but you
may be the only show in
town,” Maine says, adding
that this is especially
true in rural areas where
community resources
might be lacking.
Maine runs a private
practice in West Hartford,
Conn., and is a past
president of NEDA.
She says the first thing
counselors should
ask themselves when
encountering a client
with an eating disorder
or body image issue is
whether another accessible
resource exists that would
be better for the client. If
an eating disorder specialist
practices in the area and
can treat the client, that
might be preferable because
working with a specialist
generally produces better
outcomes, Maine says. But if that is not
an option, Maine suggests that counselors
do everything they can to shore up their
own knowledge of eating disorders while
continuing to work with the client. This
Of the 30 million
Americans who will
experience an eating
disorder during their
lifetime, one-third will
be men. Moreover, up
to 43 percent of men
are dissatisfied with
their bodies.
{
T
hirty million Americans will
struggle with a clinically
significant eating disorder such as
anorexia nervosa, bulimia nervosa or binge
eating disorder at some point in their lives,
according to the National Eating Disorders
Association (NEDA).
Pressure to conform to the “thin ideal”
starts early. The NEDA website indicates
that between 40 and 60 percent of girls
ages 6-12 are worried about their weight or
becoming too fat.
In fact, for many years, eating disorders
were thought to affect primarily adolescent
girls and young adult women. In recent
years, though, research has dictated that
medical and mental health professionals
widen their scopes and stay alert for eating
disorders across racial, cultural, gender and
age lines.
A case in point: Of the 30 million
Americans who will experience an eating
disorder during their lifetime, one-third will
be men. Moreover, up to 43 percent of men
are dissatisfied with their bodies, according
to NEDA.
Older women aren’t insulated from eating
disorders either. A study published in
2012 in the International Journal of Eating
Disorders found that 13 percent of women
age 50 and older reported having symptoms
of eating disorders. In the online survey
of 1,849 American women, 79 percent
of the older women said their weight or
shape affected their self-perception, and 36
percent acknowledged dieting at least half
the time over the previous five years.
Considering the statistics, it’s safe to say
that most counselors — including those
who don’t specialize in eating disorders and
body image issues — are likely working with
July 2013 | Counseling Today | 31
{
{
“Research has
shown that mothers
who diet and value
the thin ideal have
daughters who also
diet and struggle
to achieve society’s
standard of beauty.”
to Prevention and Treatment, which ACA
published earlier this year. A portion of
those people will engage in maladaptive
eating or exercise practices, and then a
small portion of those people will go on
to develop eating disorders, Choate says.
Binge eating disorder, in particular, has
been receiving more attention lately. In
the fourth edition of the Diagnostic and
Statistical Manual of Mental Disorders,
binge eating disorder was diagnosable
only under the category “eating disorders
not otherwise specified.” In the DSM-5,
released in May, anorexia, bulimia and
binge eating disorder have their own
categories. A fourth category is “feeding
and eating conditions not elsewhere
classified.”
In cases of binge eating disorder,
Choate says, some clients binge to cope
with their negative emotions. Other
clients develop binge eating disorder
through dieting and harboring an
overvaluation of weight and shape, which
leads to the initial instance of binge
eating. “Over time, a client feels trapped
in a cycle of dieting, followed by eventual
bingeing, followed by subsequent feelings
of shame, failure [and] low self-esteem for
having ‘failed’ at dieting efforts. Which
then leads to resolve to try harder next
time, resulting in a repeat of the cycle,”
explains Choate, a member of ACA. “It
is very hard to break out of this cycle
without outside support. This is where
counselors serve an important role.”
Choate thinks recognition of binge
eating as a standalone disorder is
significant, in part because both the act
of binge eating and binge eating disorder
have been increasing in men and women
across all races and ethnicities. She
says binge eating disorder also deserves
attention because it can lead to medical
complications normally associated with
obesity.
Many clients initially present to
counseling with a variety of other issues,
revealing their eating or body image
concerns only after they become more
comfortable with the counselor, Choate
says. That is why counselors should
screen clients for eating, weight and
shape concerns as part of the intake
process, she says.
Generally, counselors already ask
clients a few questions about sleeping
and eating, Choate says. This offers
a natural segue into questions about
can include reading current professional
literature on the topic, seeking resources
from organizations such as NEDA and
searching for available training.
Sometimes, a client won’t disclose
eating or body image issues at the onset
of counseling. In such instances, the
therapeutic relationship may develop
before the counselor recognizes the
symptoms, says Susan Belangee, a private
practitioner in Canton, Ga., who has
researched eating disorders for more than
a decade. “At this point,” she says, “it may
be unethical to refer the client elsewhere
for fear of abandoning the client and
interrupting the healing process.” In such
cases, supervision and consultation will
be key, says Belangee, a member of the
American Counseling Association.
It is important for counselors to
understand that, specialist or not, they
shouldn’t go it alone when treating a
client with an eating disorder or body
image issue, Maine says. Collaboration
with other providers is a must and might
include a dietician, a physician and a
psychiatrist, she says.
Just ask
Millions of men and women possess
a negative image of their bodies, says
Laura Choate, an associate professor of
counselor education at Louisiana State
University and the editor of Eating
Disorders and Obesity: A Counselor’s Guide
32 | ct.counseling.org | July 2013
general eating patterns (Do you ever diet?
Do you follow rules about your eating?)
and about bingeing (Have you ever felt
a loss of control over eating? Have you
ever done anything to compensate for the
food you have eaten?).
“Incorporating these types of screening
questions into routine intakes can
help on the front end,” Choate says.
“Based on findings and depending on
the counselor’s level of expertise, he or
she can either conduct more extensive
assessment of the problem or refer to
another mental health professional who
specializes in the treatment of eating
disorders.”
Belangee recommends that counselors
take a holistic approach in their initial
assessment. In addition to asking about
eating and exercise concerns and body
image beliefs, it may be wise to inquire
about the client’s family of origin, she
says. This can help counselors learn what
values the client internalized growing up
and how those values might be linked to
what the client is dealing with currently.
“If a counselor suspects an eating
disorder issue, it makes sense to
investigate the factors that research
has shown to be correlated with eating
disorders,” Belangee says. “Personality
traits, such as seeking approval from
others or perfectionistic tendencies, play a
role in the development and maintenance
of eating issues. Thus, using some type of
personality assessment could be helpful.
Other research has shown that mothers
who diet and value the thin ideal have
daughters who also diet and struggle
to achieve society’s standard of beauty.
Disordered eating patterns and full-blown
eating problems start from a sense of
feeling ‘less than,’ so listening for where
the client feels this may provide clues to
the heart of the issue.”
Environmental impact
According to Maine, an eating disorder
is formed much like a perfect storm,
meaning that no single element or event
in a person’s life can be pinpointed as
the “cause” of the disorder. Instead,
factors such as genetics, life events, family
influence and cultural pressures line up to
create an environment in which an eating
disorder is conceived and then thrives.
After many years spent in the trenches
treating eating disorders, Maine has
concluded that nurture is a bigger factor
“Other research has shown connections
between trauma and/or abuse and eating
pathology,” Belangee continues. “Perhaps
the environment was so chaotic and
The combination
of negative body
image and dieting is
one of the strongest
risk factors for
development of an
eating disorder.
{
dieting is one of the strongest risk factors
for development of an eating disorder,
Choate says.
Families have the capacity to negate —
or reinforce — those media and cultural
influences, Choate says. For example, a
daughter’s body image is highly influenced
by how her mother feels about her own
body, Choate says. If a mother regularly
critiques her own body, her daughter is
likely to grow up thinking it’s normal to
concentrate on her own flaws.
Belangee echoes the impact of the family
environment. Research has long shown
that family variables such as beliefs and
values about size, shape and dieting are
connected to eating disorder symptoms
and behaviors, she says. “We learn by
watching and interacting with our family
members. If a child grows up in an
environment where belonging is achieved
by looking a certain way or eating [or]
avoiding certain foods, or striving to be
the best and second place is never good
enough, the child will most likely strive to
display those same values in order to gain
love, acceptance and approval.”
{
than nature. “Yes, you have some genetic
factors, but it’s really an intergenerational
attitude toward weight, food and body
image that will tip the scales,” says Maine,
the author or coauthor of five books on
eating disorders and body image and also
a contributor to Choate’s book.
According to Choate, a triad of
sociocultural influences affects a person’s
body image: media and the larger culture,
family and peers. During childhood,
family often holds the largest influence,
Choate says, but media and peers gain the
upper hand during adolescence and early
adulthood.
The media, in particular, place great
emphasis on the “thin ideal,” Choate
says. If people buy into that, they tend
to tie their worth and value as a person
to their shape and weight, she explains.
The thin ideal portrayed in the media is
for the most part unattainable, but the
inability to “measure up” can leave some
people with feelings of guilt and lead
to negative body image, low self-esteem
and an unhealthy focus on dieting. The
combination of negative body image and
July 2013 | Counseling Today | 33
New!
Eating Disorders
and Obesity:
A Counselor’s Guide to Prevention and Treatment
edited by Laura H. Choate
“This thoughtful and thorough
compilation, written by authorities
in the field, belongs on every
counselor’s reference shelf—not just
those practitioners who treat eating
disorders and obesity. This gem of
a tome contains rich and essential
information for all counselors.”
—Cynthia M. Bulik, PhD
Director, UNC Eating Disorders Program
The University of North Carolina
at Chapel Hill
Both practical and comprehensive,
this book provides a clear framework for the assessment,
treatment, and prevention of eating disorders and obesity.
Focusing on best practices and offering a range of current
techniques, leaders in the field examine these life-threatening
disorders and propose treatment options for clients of all ages.
This text, written specifically for counselors, benefits from
the authors’ collective expertise and emphasizes practitionerfriendly, wellness-based approaches that counselors can use in
their daily practice.
Parts I and II of the text address risk factors in and
sociocultural influences on the development of eating
disorders, gender differences, the unique concerns of clients of
color, ethical and legal issues, and assessment and diagnosis.
Part III explores prevention and early intervention with highrisk groups in school, university, and community settings. The
final section presents a variety of treatment interventions, such
as cognitive–behavioral, interpersonal, dialectical behavior,
and family-based therapy.
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34 | ct.counseling.org | July 2013
damaging that the child struggles to
cope and belong, feeling the lack of love,
approval and acceptance. Both situations
set the stage for the child to feel uncertain
about himself or herself, to question how
he or she will find a place to fit in and to
live fruitfully. Ultimately, though, it is the
individual’s decision about who he [or]
she is in the face of these circumstances
that plays the biggest role in the
development of eating disorder symptoms
and behaviors.”
Perfectionism, where a person
consistently judges only in terms of good
or bad, black or white, with no variable in
between, can also set the stage for eating
disordered behaviors, Maine says. Loss
can play a role as well, she says. Losses
may be concrete, such as the death of a
loved one, or more symbolic, such as an
older sibling leaving for college.
Among adolescents and young adults,
eating disorders tend to develop during
times of stress and transition, Maine says.
Times of high vulnerability tend to be
between the ages of 13 and 15 and the
ages of 17 and 19, she says.
“When you think about those two
ages, there’s a lot going on,” she says.
Between 13 and 15, kids are getting used
to their rapidly changing bodies, while
receiving less attention and structure
from adults. Between 17 and 19, young
adults are oftentimes preparing to leave
home and become more independent
for the first time. The stress of those or
other transitions can be a key trigger in
developing an eating disorder, Maine says.
Peer subcultures also exert influence,
Choate says. Being part of a group
that places emphasis on appearance —
whether a social clique, a sports team or
a sorority, for example — can ratchet up
the pressure.
In addition, cultural pressures related
to weight and shape can feel ever present
on social media. “Whereas in the past, a
client with an eating disorder might have
felt isolated, she can now go online to
receive ‘support’ from others who may
cheer her on,” Choate says. “A client
can also gain information about dieting,
excessive exercise and ways to compensate
for calories. Further, social media sites
give her ideals to strive for — models
to emulate, body types to compare
herself to. As an example, the current
‘thigh gap’ trend, where girls diet and
exercise excessively in order to achieve a
‘gap’ between the top of their thighs, is
currently popularized on websites such as
Pinterest and Instagram, among others.” ‘Not just a young woman problem’
As the statistics have begun to show,
eating disorders and body image issues
aren’t restricted to adolescent and young
adult women.
Maine points to research from 2007
indicating that nearly one-quarter of
diagnosable cases of eating pathology
occur in males. Although men exhibit the
same kinds of eating disordered behaviors
as women do, many men arrive at eating
disorders via excessive exercise, Maine
says. They may be eating, but not enough
to support the amount of exercise in
which they’re engaging, she says.
In general, boys and men are valued
for personal aspects beyond weight or
shape, such as financial success and
athletic ability, Choate says. So even if
an adolescent male has a negative body
image starting in boyhood, it may not
affect his overall self-esteem because he
{
feels valued for other things.
That said, men — like women — are
still affected by cultural pressures to be
thin, Choate says. In fact, the ideal image
confronting men — thin and muscular
— is growing increasingly unrealistic, just
as it is for women. Choate points to the
change in the shape and muscularity of
G.I. Joe dolls over the years as an example
of the cultural message that boys and men
are receiving.
Men who are struggling with body
image issues or eating disorders may use
different language than women who
are dealing with these issues, Belangee
notes. For example, men may express the
desire to be “toned” or “ripped,” whereas
women may be more likely to focus on
being a certain weight or dress size.
Eating disorders in both men and
women can sometimes be the result of
bottled up emotions and feelings, Maine
says. However, men are more likely than
women to be discouraged from expressing
those feelings, she points out, and if the
feelings aren’t expressed verbally, it is easy
for self-destructive behaviors to crop up.
An important first step in working
with men with eating disorders is to help
them get past the shame, Maine says.
This includes reminding them that they
are far from the only men dealing with
this problem. Additionally, she says,
counselors can help men understand what
function the eating disorder plays in their
life and then supply them with healthier
ways of dealing with those issues.
Women all across the age spectrum can
experience eating disorder symptoms and
body image issues. Unfortunately, Maine
says, our culture and medical system don’t
tend to focus as much attention on adult
women’s issues, so eating disorders among
older women often fly under the radar.
As a culture, we tend not to believe that
adults still struggle with eating disorders
and body image issues, says Maine, who
in 2005 coauthored the book The Body
Myth: Adult Women and the Pressure to Be
Perfect with Joe Kelly.
Women in midlife experience a host
of potential transitions, Belangee says,
including menopause, children “leaving
the nest” and the loss of a spouse,
whether through divorce or death. Each
of these transitions can result in stress
and questions of identity — “Who am I
now?” As counselors, recognizing these
{
Men who are struggling
with body image issues
or eating disorders may
use different language
than women who are
dealing with the same
issues. For example, men
may express the desire to
be “toned” or “ripped,”
whereas women may be
more likely to focus on
being a certain weight or
dress size.
July 2013 | Counseling Today | 35
transitions goes hand in hand with taking
a holistic view of clients, Belangee says.
Counselors need to consider factors such
as how clients view themselves, their sense
of belonging and whether they turn to
food as a way of coping, she says.
Maine agrees and adds fertility issues,
child rearing, aging, career challenges
and caring for aging parents to the list of
stressors adult women regularly confront.
But most of those transitions aren’t
recognized by society at large. “When you
move from high school to college, there
is recognition and acknowledgment,”
Maine says. “Once we get to be adults,
that kind of acknowledgment doesn’t
happen.”
Belangee points to a 2010 study from
Oregon Health & Science University
showing that women between the ages
of 65 and 80 were just as likely as young
adult women to feel fat or worry about
their body shape. Among older women,
the effects of an eating disorder can be
even more dire, Belangee says, because
their immune systems are generally
not as strong as those of their younger
counterparts and their general health can
decline more rapidly.
Any mental health clinician treating
adult women, regardless of specialization,
36 | ct.counseling.org | July 2013
is likely to come across either subclinical
or full-blown eating disorder issues,
Maine says. “It has to be on your radar
screen that eating disorders are not just a
young woman problem,” she says.
Adult women are much less likely
than younger women or adolescent girls
to have pure anorexia or pure bulimia.
Instead, Maine says, adult women may
present with a mix of symptoms that
would fall under the DSM-5’s category
of feeding and eating conditions not
elsewhere classified. Counselors must
be careful not to overlook these women
simply because they do not clearly meet
the criteria for one specific category
of eating disorder or another, Maine
cautions.
Compounding the problem, she says,
is that many adult women with eating
disorder symptoms are embarrassed
by their struggle and do not think it is
acceptable to talk about. And, oftentimes,
their health care providers don’t bother
to ask. In fact, Maine says, because the
U.S. health care system is typically more
focused on combatting obesity, anyone
who loses weight is given kudos, not
questioned about potentially unsafe
eating habits.
Considering culture
Mental health clinicians tend to be
less likely to recognize eating disorders
in female clients of color, says Regine
Talleyrand, associate professor in the
counseling and development program at
George Mason University. That’s partly
due to stereotypes that women of color
are somehow protected from eating
disorders because of their cultural norms,
and partly due to stereotypes that only
young Caucasian women develop eating
disorders, she says.
But research has shown that women
of color present with eating disorder
symptoms at a rate equal to or higher
than that of Caucasian women, says
Talleyrand, a member of ACA who
contributed a chapter on cultural
considerations to Eating Disorders
and Obesity.
However, minority clients may
experience eating disorders, body image
and treatment for these issues differently
than do nonminority clients, says Ioana
Boie, an assistant professor of counseling
at Marymount University in Arlington,
Va., who also contributed to Choate’s
book. Boie says minority clients tend to
be underdiagnosed, undertreated and
underrepresented in treatment programs
and research studies. These clients also
tend to receive lower standards of care
due to the lack of recognition and are
more likely to discontinue treatment or
have poor prognoses, according to Boie.
What is needed, Boie says, is better
training on cultural sensitivity and more
culturally sensitive assessments and
treatments. For example, she says, family
therapy and family education may need
to take a more prominent role when
working with minority clients with eating
disorders because of the pronounced role
that family plays in these clients’ lives.
In addition, when it comes to clients of
color, Talleyrand says counselors should
consider factors other than peer group,
family and media influence that may
contribute to the development of eating
disorders. She says these additional factors
may include immigration, acculturative
stress, racism, racial/ethnic identity,
socioeconomic status and more.
Counselors should never assume that
a client of color is somehow culturally
“protected” from developing an eating
disorder, Talleyrand warns. “All women
should be assessed for all types of
disordered eating behaviors and attitudes,
given the fact that 90 percent of women
experience body dissatisfaction. I would
also say that counselors need to start
looking beyond anorexia and bulimia
since binge eating disorder is much more
common among the general population,
is finally being [given] its own diagnosis
in the DSM-5, and some women of color
engage in greater or equal levels of binge
eating behaviors in comparison with their
white counterparts.”
Boie contends more research is needed
in this area, including assessments to
better capture body image dissatisfaction
from a diverse perspective. These
assessments should encompass concerns
that are atypical for white clients, such
as hair type, skin color or eye and nose
shape, she says.
“For example, Mexican-American
women may be less preoccupied about
thinness but [more preoccupied] about
maintaining a guitar-shaped body, with
larger bust and hips and a thinner waist,”
says Boie, a member of ACA. “Therefore,
a clinician may miss the typical drive for
thinness.”
“Remember to get a good picture of
how culture may impact women’s issues
depending on their cultural identity, level
of acculturation, generational status [and]
intersection with other dimensions of
diversity [such as] socioeconomic status,
sexual orientation, etc.,” she says. Rather
than attempting to fit these clients into a
mold, Boie believes counselors must try
to understand the influence of cultural
values and norms, both on clients’
eating disorders and body image issues,
and on the treatment and counseling
relationship.
Finding the best way forward
Choate’s mission in putting together
the book Eating Disorders and Obesity was
to provide counselors with a one-stop
shop for best treatment practices and
guidance for additional resources. The
treatments shown to be most effective
in treating eating disorders, Choate
says, are enhanced cognitive behavior
therapy (CBT-E), family-based therapy
for child and adolescent clients with
anorexia, interpersonal therapy (IPT) and
dialectical behavior therapy (DBT).
With CBT-E, the first phase targets
normalized eating, including three meals
and two snacks a day. Once clients make
that switch, they usually find their urge
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{
Additional resources
Want to expand your knowledge on
this topic? Here are some good places
to start:
n Eating Disorders and Obesity:
A Counselor’s Guide to Prevention
and Treatment, edited by Laura
Choate, and published by ACA.
This new book offers a practical and
comprehensive look at the assessment,
treatment and prevention of eating
disorders and obesity (visit the ACA
Online Bookstore at counseling.org/
publications/bookstore).
n ACA’s Journal of Counseling &
Development featured a special section
titled “Assessment, Prevention and
Treatment of Eating Disorders: The
Role of Professional Counselors,”
guest edited by Laura Choate, in its
July 2012 issue.
n “Counseling College Women
Experiencing Eating Disorder Not
Otherwise Specified: A Cognitive
Behavior Therapy Model” by Laura
Choate, Spring 2010 Journal of
College Counseling
n “The School Counselor’s
Role in Addressing Eating
Disorder Symptomatology Among
Adolescents” by Juleen K. Buser,
VISTAS Online, 2012 (counseling.org/
knowledge-center/vistas)
n “Eating Disorders Among
Male College Students” by Joseph
Birli, Naijian Zhang and Vickie
Ann McCoy, VISTAS Online, 2012
(counseling.org/knowledge-center/vistas)
n “Drama Therapy as a
Counseling Intervention for
Individuals With Eating Disorders,”
by Dixie D. Meyer, VISTAS Online,
2010 (counseling.org/knowledge-center/
vistas)
n National Eating Disorders
Association (nationaleatingdisorders.
org)
n Laura Choate also recommends
the website Eating Disorders
Resources for Recovery (bulimia.
com) and the book Overcoming Binge
Eating by Christopher G. Fairburn,
published by Guilford Press in 1995.
{
38 | ct.counseling.org | July 2013
to binge decreases, Choate says. During
the second phase, the client and counselor
begin looking at the cognitive side of the
issue. They explore how the client might
have overvalued weight and shape in
the past and how the client can handle
current and future problems without
turning to eating or exercise.
Choate points out that although
CBT-E is the most effective evidencebased treatment for eating disorders,
it is only effective in up to 60 percent
of cases. That clearly shows that more
research on effective treatments is
necessary, Choate says.
IPT has been tested against CBT-E.
Although IPT is slower to work initially,
at the one-year follow-up after clients
finish treatment, CBT-E and IPT were
shown to be equally effective, according
to Choate. IPT doesn’t focus on food,
weight or shape at all, she says. Instead,
the focus of treatment is on improving
the person’s interpersonal competence
and relationships. The theory behind it,
Choate explains, is that eating disorders
develop as a result of interpersonal
conflicts. For example, a female client
may not be getting her needs met
in relationships, or an adolescent
transitioning through puberty might
be struggling in her relationship with
her parents. As clients learn to develop
healthy relationships and get their needs
met with the help of IPT, the importance
of weight, shape and using food as a
coping mechanism seems to diminish,
Choate says.
DBT has shown effectiveness with
clients dealing with binge eating, Choate
says. The treatment assists them with
developing healthier coping skills,
tolerating distress and regulating their
emotions.
Family-based therapy is appropriate for
young clients who have anorexia and are
still living at home, Choate says. With
this approach, parents temporarily take
control of feeding the child until the
child gets back to a healthy weight. At
that point, control over eating is gradually
transferred back to the child.
Maine says using relational-cultural
theory (RCT) is effective in treating
adult women (a chapter of Choate’s
book is also devoted to RCT). Unlike
approaches based in medical models,
which can be depersonalizing and
objectifying, Maine says RCT focuses on
the client’s resources and self-knowledge.
RCT aims to examine the function of
the eating disorder, which exposes for
clients how it has become a Band-Aid for
other issues such as feeling inadequate,
powerless or confused about how to get
their needs met.
RCT also places the counselor and
client on equal footing, Maine says,
with each serving as a key component in
solving the problem. “I will say, ‘I am the
expert in eating disorders, but you are the
expert of you. Alone, I can’t solve your
problems.’ This equalizes the situation,”
Maine says. “I’m not more important. I’m
just a guide.”
In her counseling practice in Concord,
Mass., ACA member Alice Rosen uses
what she calls a “nondiet” approach with
clients with eating disorders and body
image issues. These clients make up
approximately 75 percent of her caseload.
The diet mentality, Rosen explains,
suggests to people that something is
wrong with their bodies and that they
don’t have the resources within themselves
to fix it, so they must rely on an external
expert. A nondiet approach, on the
other hand, teaches clients that they are
qualified to be the expert if only they will
listen to the cues their body provides,
Rosen says.
Rosen teaches her clients mindfulness,
encouraging them to pay nonjudgmental
attention both to their body’s cues and
the food they eat. Mindfulness helps
clients validate their hunger cues and
realize true pleasure in eating and satiety,
Rosen says. She also recommends that
clients find gentle ways to feel at home in
their bodies, such as practicing restorative
yoga. For the emotional healing
component to eating disorders and body
image issues, Rosen gravitates toward the
Internal Family Systems Model.
Counselors working with eating
disorders and body image issues need a
whole toolbox from which to choose,
Maine says. But even as they stay abreast
of all the effective treatments available,
they also must know about the client
in front of them and what the best
treatment fit might be based on that
particular client’s life, she says.
Seeing the whole client
In her work with clients with eating
disorders, Belangee applies an Adlerian
approach, which she says encourages
counselors to understand who clients
are as whole human beings within their
environments. “[Alfred] Adler proposed
that it was the desire to belong and
find a place to fit in and contribute to
society that motivated human behavior,”
Belangee says.
With an Adlerian approach, family
dynamics play an important role because
the family is the first place where
individuals strive to find a place to belong
and contribute, Belangee says. “Another
key tenet of the theory is one’s sense of
self in relation to the world,” she says.
“Do we view ourselves as less than or
inferior to others in some way?”
“Adler called the culmination of these
factors the ‘life style’ or ‘game plan for
living,’” she continues. “The cornerstone
of mental health is how much we feel
that sense of belonging and contribute
to the growth and well-being of our
society. As we grow up and our circle
widens, we then encounter more people
and more situations that test our coping
skills and sense of self. When we view a
situation as more than we can handle, we
may choose healthy coping resources, or
if the stress is chronic, we may find our
coping resources inadequate to meet the
perceived demands of the situation. It is
in these situations where someone might
turn to eating disorders as a means of
coping.”
Similar to some other models, an
Adlerian approach assumes that an
eating disorder serves a purpose for the
client. The first step for the counselor,
then, Belangee says, is to get a complete
picture of who the client is and walk
in the client’s shoes in the hopes of
understanding what purpose those
behaviors serve and why that coping
mechanism makes sense to the client.
“We could assume it’s about thinness or
control, but we might be very wrong,”
she says.
Counselors using an Adlerian approach
might ask clients Adler’s famous question:
If you didn’t have this issue in your life,
how would your life be different? Peeling
back the layers, the counselor might
uncover what the client is afraid of.
“Maybe the client is fearful of rejection,
so he [or] she makes excuses of needing
to go to the gym or of not being hungry
to get out of dates or activities with the
potential for meeting people,” Belangee
says. “The goals for the symptoms are
as varied as the clients’ perceptions of
themselves and how they approach life.”
“Once all the pieces of the puzzle are
uncovered,” she continues, “the counselor
and client can work together to create
more effective coping strategies to deal
with the thoughts and emotions once
handled by eating disorder symptoms
and behaviors. This part of the process is
very scary for the clients, particularly for
those who struggled for years with eating
disorder symptoms. The more concrete
the strategy, the better able the client is to
use it. Taking time in sessions to practice
the new skills is always a good idea.”
The potential for prevention
Choate points out that not everyone
who has a negative body image also has
an eating disorder, but everyone who has
an eating disorder did start out with a
negative body image. “From a prevention
July 2013 | Counseling Today | 39
aspect, that’s so important to note,” she
says. “If we can intervene there and help
clients to develop a healthier attitude
toward their own weight and shape, to
see there are other aspects to consider in
their overall worth and value, that’s where
eating disorders are highly preventable.”
Research Choate has conducted
during the past few years has resulted
in a model of body image resilience. In
an article published in the journal Sex
Roles last year, Choate and two colleagues
examined factors present in young
women who possess positive body image.
These factors include:
n
Family support and open
communication
n
Rejection of sociocultural pressures to
achieve the thin ideal
n
Rejection of the “superwoman myth,”
or the idea that women have to do it all
n
Active coping skills
n
Positive physical self-concept,
encompassing an appreciation for the
body and what it can do, not just how it
looks
The “Body Project” by Eric Stice
and Heather Shaw has the strongest
empirical support of any prevention
program designed for those at risk for
negative body image and eating disorders,
according to Choate. Stice and Shaw
contributed a chapter to Choate’s book
on the project, which is aimed at helping
young women recognize the costs of
seeking the thin ideal.
When clients of any age go through
stressful times, Maine says, they tend to
change their eating habits. That might
include undereating, bingeing or some
combination of the two. For that reason,
it is crucial that counselors ask clients
about their eating habits when they are
facing stress or transitions, she says.
Maine recommends that counselors
normalize clients’ eating changes and
remind them that many people act
similarly when undergoing stressful
times. Counselors can then teach clients
self-soothing alternatives to eating or
restricting their food intake to provide
their emotions an outlet.
40 | ct.counseling.org | July 2013
The best help possible
Counselors who find themselves
working with clients with eating
disorders must keep ethical
considerations in mind, Choate cautions.
First, be mindful that treating eating
disorders is a highly specialized area
of practice that takes considerable
training, knowledge and skills, she says.
Counselors should know their scope of
competence and when they may need
to refer.
Second, she says, remember that an
eating disorder is not something any
counselor should attempt to treat on his
or her own. The counselor must work
as part of a multidisciplinary team that
might include a physician, a nutritionist,
a psychiatrist and others.
When it comes to eating disorders,
the subject of client autonomy can raise
ethical questions for counselors, Choate
says. Counselors have an ethical mandate
to promote a client’s ability to make
his or her own choices, but counselors
also have an ethical responsibility to
promote the client’s well-being, she
says. Sometimes a counselor, working
alongside a physician, may have to
support involuntary hospitalization
if that becomes the only option for
maintaining the client’s well-being.
It is also crucial for counselors to be
aware of their personal feelings about
body image and eating disorders,
Belangee says. Counselors need to
understand how they feel about their
own bodies, be aware of any issues they
have related to food and know their
own triggers, she says. Some counselors
end up in the profession after their
own personal histories of dealing with
eating disorders. These counselors would
be wise to seek consultation or even
counseling of their own while working
with this population, Belangee says.
Choate agrees. “Don’t neglect selfawareness and self-care when working in
this area. Just like our clients, counselors
are vulnerable to societal pressures related
to weight, shape and eating, and we have
to make sure we are working on our own
issues in this area.”
The field of eating disorders treatment
is complex and challenging, but Choate
says it is important for counselors to
realize and embrace the important
role they have to play in preventing
and treating these biopsychosocial
issues. “Whether or not we choose to
specialize in this area, our vital role
in prevention, early detection and
treatment cannot be overstated,” she
says. “As counselors, we are certainly on
the front lines in our ability to provide
primary or targeted prevention programs
in both schools and communities. In
addition, because of the breadth of
our work roles and settings, we may
also be among the first professionals to
detect the presence of disordered eating
symptoms in our clients. Therefore, we
have a responsibility to be as prepared
as possible to effectively assist our
clients — ideally before their symptoms
develop into chronic and potentially lifethreatening conditions.”
u
To contact the individuals interviewed
for this article:
n Email Susan Belangee at
[email protected]
n
Email Ioana Boie at
[email protected]
n
Email Laura Choate at
[email protected]
n
Visit Margo Maine at mwsg.org
n
Email Regine Talleyrand at
[email protected]
n
Email Alice Rosen at alice.rosen@gmail.
com or visit theconsciouscafe.org u
Lynne Shallcross is the associate
editor and senior writer for
Counseling Today. Contact her at
[email protected].
Letters to the editor:
[email protected]
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July 2013 | Counseling Today | 41
Keeping it brief
By Stacy Notaras Murphy
Solution-focused brief therapy builds on client strengths and aims for
positive outcomes rather than trying to arrive at a complete understanding of the client’s past
H
ere are some popular
misconceptions about brief
therapy:
n It sacrifices a real therapeutic alliance.
n It is only popular because insurance
companies love it.
n It doesn’t work long term.
Many counselors with in-depth training in
brief therapy models are quick to dispel these
myths and contend that brief therapy can
help clients zero in on real causes for problem
issues without getting lost in detail and old
history. Others emphasize the way that brief
therapy, often known as solution-focused
brief therapy (SFBT), helps clients build
substantial solutions rather than just resolve
specific problems. Rooted in the 1950s work
of Milton Erickson and further developed
by the husband-and-wife team of Steve de
Shazer and Insoo Kim Berg in the 1980s, the
brief therapy model highlights and activates a
client’s strengths to help change a situation.
Studies have shown the model’s
effectiveness in working with clients with
depression, antisocial adolescents, prison
populations and even parenting skills groups.
Its proponents say that, with less time spent
on history taking and diagnoses, the SFBT
approach is well suited to the new realities of
limited insurance benefits and the increasing
need for community mental health outreach.
Mike Kozlowski, an American Counseling
Association member who works at Columbia
River Mental Health Services in Vancouver,
Wash., is one clinician who has witnessed
the misconceptions that often swirl around
SFBT. He says he appreciates the opportunity
to set the record straight.
“Many counselors who favor long-term
approaches often think brief and solutionfocused approaches are invalidating to the
client’s experience because they only concern
themselves with understanding enough of
the problem to find a solution to it,” he says.
“I think counselors feel this way because
they walk around with the assumption that
the problem needs to be completely known
in order to solve it. This means diving into
client histories trying to understand how
problems began.”
Clients may harbor some of these false
impressions as well. “Sometimes clients
also have the perception that they need
long-term work in order to feel better,”
Kozlowski says. “I think this is due to the
portrayal of counseling in popular culture.
This has created the client assumption
that the counselor needs to completely
understand the past in order to help the
client in the present.”
Counselors who practice brief therapy
emphasize understanding the problem within
the immediate moment, Kozlowski explains.
“I think this approach is becoming more
and more necessary [because] research in
psychotherapy and counseling is suggesting
that the number of sessions attended by most
clients is one,” he says.
Mat Trammel, cofounder of the Fort Worth
Brief Therapy Center in Fort Worth, Texas,
gravitated toward SFBT after exploring the
client-centered, Rogerian approach and the
interpersonal process style. “The premise
behind brief therapy models is that change
can take place suddenly,” he says. “Through
creative questioning aimed at discovering
exceptions to when, how and where a
problem occurs, SFBT practitioners also
rely heavily on a client’s personal strengths,
creativity and expertise with [his or her] own
life as opposed to assuming a directive role or
expertly telling clients how they should solve
their problems.”
Trammel notes that, rather than
emphasizing childhood and early life
experiences, counselors applying brief
therapy models often follow their curiosity
to help clients recognize the “here and now”
situations in which the identified problems
do not have influence. “Understanding
the nature of a problem is not typically the
focus of brief therapy models and is not
always necessary before forward progress
can take place,” he says. “While solution-
July 2013 | Counseling Today | 43
{
Additional resources
n Mastering the Art of SolutionFocused Counseling, second edition,
by Jeffrey T. Guterman, published
by ACA in 2013. Provides a
comprehensive and straightforward
discussion of solution-focused theory
and describes how the model can
be used throughout the therapeutic
process (available in the ACA
Online Bookstore at counseling.org/
publications/bookstore).
n Solution-Focused Counseling
in Schools, second edition, by John
J. Murphy, published by ACA in
2008 (available in the ACA Online
Bookstore)
n Brief Solution-Oriented Therapy
DVD presented by William
O’Hanlon; part of the International
Association of Marriage and Family
Counselors Distinguished Presenter
Series (available in the ACA Online
Bookstore)
n “Solution-Focused Therapy as a
Culturally Acknowledging Approach
With American Indians” by Dixie D.
Meyer and R. Rocco Cottone, Journal
of Multicultural Counseling and
Development, January 2013
n “Solution-Focused Counseling
for Eating Disorders” by Clayton
V. Martin, Jeffrey T. Guterman and
Karen Shatz, VISTAS Online, 2012
(counseling.org/knowledge-center/vistas)
n “Solution-Focused Brief
Counseling in Schools: Theoretical
Perspectives and Case Application to
an Elementary School Student” by
May Sobhy and Marion Cavallaro,
VISTAS Online, 2010 (counseling.org/
knowledge-center/vistas)
n “Solution-Focused Counseling
in Schools” with speaker John
J. Murphy, ACA Podcast Series
(counseling.org/continuing-education/
podcasts)
{
44 | ct.counseling.org | July 2013
focused therapy may utilize genograms,
family history or childhood experience,
they are not considered prerequisites to
positive change.”
Trammel also points out that SFBT
is not the sole model he uses. “I employ
rational emotive behavior therapy as
well and cognitive behavioral therapy
to some extent. In dealing with facets
of personality disorders, use of some
aspects of dialectal behavior therapy is
also beneficial,” he says. “I endeavor to
use whatever approach or model works
best for the client. I find that [SFBT]
combines nicely with other forms of
counseling.”
Kozlowski concurs. “Skilled brief
counselors know clients don’t always
fit nicely into our psychotherapeutic
boxes,” he says. “[These counselors] make
adjustments to include techniques from
other theories … in the spirit of ‘doing
what works.’”
Looking for exceptions
The Solution-Focused Brief Therapy
Association, a group affiliated with de
Shazer and Berg that promotes counselor
education and consultation, describes
the approach simply as being brief and
focusing on solutions rather than on
problems. The client and counselor
collaborate in “becoming curious” about
the times when the client’s identified
issue is not present or feels less powerful.
They work to enhance awareness of these
moments, with the client growing more
confident as a result. Instead of teaching
a client an entire new set of behaviors,
this model helps the client recognize and
build on his or her existing strengths. The
theory supposes that, because the client’s
strengths already exist, it may take less
time to put them to use in addressing the
presenting problem.
Looking for exceptions to the client’s
perceived problem is a hallmark technique
of SFBT and one that many clients don’t
expect when beginning the counseling
process, Kozlowski says. “I specifically
remember one client suffering from
crippling anxiety whom I asked, ‘So, tell
me about the times where you are not
anxious.’ She was so surprised that she
almost fell out of her chair,” he says. “She
told me that all of her other counselors
had only talked to [her about] triggers to
anxiety, and no one had ever asked her
about when the problem wasn’t occurring.”
SFBT practitioners may apply other
interventions, including “problem-free”
talk to build rapport and learn about the
client’s other resources. They may also
ask clients to rate their feelings about the
problem on a scale of 1 to 10 and inquire
about coping skills. Another classic
technique, although not unique to SFBT,
is asking the “miracle question,” which
invites the client to consider how life
would change if the presenting problem
miraculously disappeared. Used together,
these interventions may help clients stop
focusing on what is wrong and instead
move toward naming what is going well
and considering how to enhance the
positive.
The brief therapy model also uses
homework and taps into community
resources to help clients, notes Mira
Mullen, a licensed professional counselor
and ACA member in Juneau, Alaska. “I
often use handouts from [Kate CohenPosey’s] More Brief Therapy Client Handouts
for anxiety, depression, mindfulness
breathwork, relationships, etc. I have
resources available in my office for
community supports, 12-step groups and
other agencies because, frequently, patients
are eager to accept help from food banks
and charitable organizations,” she says.
Kozlowski recalls working with a
client with posttraumatic stress disorder
who assumed she would need years of
counseling to overcome a sexual assault
and an abusive childhood. “When we
were discussing the problems in therapy, it
turns out her main problem was actually
dealing with her musician boyfriend who
was out late, and she assumed he was being
unfaithful, even though he hadn’t been. So,
she would yell at him when he would come
home, and he would react by yelling at her,
which reminded her of the emotional abuse
she had experienced in the past.”
“By probing for exceptions and
punctuating her solutions to the
problems,” Kozlowski continues, “we
discovered she was actually very good
at communicating her needs to her
boyfriend during other times in their
relationship. After a little coaching and
practice in applying her already existing
skills to her conversation with her
boyfriend when he came home late from a
concert, she felt well enough to terminate
counseling. To my knowledge, she hasn’t
returned for services since.”
READ
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July 2013
Counseling Today,
the CT Learning Test,
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Earn 1 CE credit by reading the selected article in this issue. Read the article identified below and answer 3 of 4 questions correctly to earn 1 CE credit.
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Learning Objectives: Reading this article will help you:
1) Reflect on how counselors, regardless of specialty, can embrace their role in working with clients to prevent, detect and treat eating
disorders and body image issues.
2) Understand ways in which eating disorders and body image issues stretch across all races, ethnicities, cultures, genders and ages.
Continuing Education Examination
1) Of the 30 million Americans who will experience an eating disorder
during their lifetime, one-third will be men.
____ True ____ False
2) Counselors are less likely to recognize eating disorders in female
clients of color. This is partly due to stereotypes that:
a) Women of color are somehow protected from eating disorders
b) Only young Caucasian women develop eating disorders
c) Male clients of color are more likely to develop eating disorders
d) Both a and b
3) Which treatment is shown to be appropriate for young clients who
have anorexia and are still living at home?
a) Enhanced cognitive behavior therapy (CBT-E)
b) Family-based therapy
c) Interpersonal therapy (IPT)
d) Dialectical behavior therapy (DBT)
4) Which factor is not typically present in young women who possess a
positive body image?
a) Family support and open communication
b) Rejection of sociocultural pressures to achieve the thin ideal
c) Adoption of the “superwoman idea”
d) Active coping skills
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July 2013 | Counseling Today | 45
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46 | ct.counseling.org | July 2013
Kozlowski acknowledges that a
psychodynamic or trauma-oriented
counselor might recommend a different
path for this client and cites this as the
fundamental difference between long-term
and brief therapy models. “Brief models
focus specifically on resolving the chief
complaint,” he says. “Solution-focused, as
I understand and practice it, focuses on
finding a solution that works well enough
for the client to function in [his or her]
day-to-day life without the need of the
therapist.”
The appeal of brief therapy
It’s natural to ask what type of client
benefits from SFBT. Because of the
model’s flexibility and positive approach,
its proponents suggest a better question
might be what type of client wouldn’t find
SFBT beneficial. “I haven’t met a client yet
where this approach hasn’t been ... helpful,”
Kozlowski says, adding that competent
supervision is a must for those seeking to
incorporate SFBT into their practices.
Kozlowski admits that at the clinic
where he works, some clients come in
thinking they need long-term counseling.
To those clients, he offers an analogy:
“People are like oceans. They are vast,
complicated and not always easy to
understand. When people come to
counseling, they often think we need to
spend the time exploring every oceanic
canyon, classifying every kind of fish and
mapping every current in order for things
to be different. While this can be true for
some, others just want to figure out how
to get from London to New York. I’m the
guy who can help you get from London
to New York. Is that something you
would like?”
Trammel agrees. “I think any person
may find a nice fit with solution-focused
work. It seems to be a good fit for
court-ordered clients, possibly due to
the externalizing of the problem and
unconditional acceptance of how they have
attempted to resolve the issues in the past.”
Brief therapy models hold appeal for
other reasons too. Namely, insurance
companies tend to be more willing to
reimburse for these sorts of services because
they often involve fewer sessions and
provide quantifiable outcome measures.
“The techniques in solution-focused
therapy, as well as its brief design, lend it
to fit well within [the insurance] process,”
says Kozlowski, who adds that a large
managed care company in his part of the
country strongly favors SFBT. “I work
in community mental health, which
primarily bills Medicaid and Medicare
for its services. Some counties here in the
Northwest have adopted solution-focused
therapy as an evidence-based practice
billable for psychotherapy.”
Outside the box
The use of brief therapy models is not
limited to the traditional counseling office.
In fact, some counselors contend that brief
therapy models lend themselves to unusual
practice locations because of their flexibility
and emphasis on goal achievement. Mullen
works as a behavioral health consultant
in a tribal Indian Health Service-funded
clinic in frontier Alaska that uses the
family home medical model. The model
brings behavioral health workers such as
counselors and social workers into medical
clinics, thus incorporating mental health
support into the traditional medical
approach. The model lends itself to SFBT
because the clients are referred as part of a
larger medical diagnosis — for example,
to consider the mental health side of a
medical diagnosis such as cancer.
Mullen gives an example of what she
does when one of the clinic’s primary care
doctors gives her a referral. “A doctor will
come see me [and] give the age, name,
social circumstances, presenting problem
and co-occurring medical issues [of the
patient]. Then we will walk together to
the assessment room the patient is in,
and the doctor will introduce me and
exit to quickly continue seeing other
patients. I will sit with a patient and do
active listening and validate [his or her]
experience in order to build rapport and
improve affect regulation. From there,
we can at times move to my office for an
additional 20 minutes or so and begin the
process of problem identification and brief
therapy.”
Mullen will conduct between one and
four visits with clients, after which she
may make referrals to a separate behavioral
health department within her facility.
She explains that a few sessions with her
can help clients solidify their goals before
launching into longer-term therapy.
Mullen concedes that it can be
challenging when clients resist the shortterm approach necessary in her clinical
work environment. She has had clients
say they like working with her and do
not want to “change horses midstream.”
In these situations, she has found herself
reframing the purpose of the sessions as
a way to teach clients what is expected in
therapy and how to use the time to their
advantage.
assumes clients have the strengths, skills
and resources to solve their own problems
— but they either forgot their skills or need
guidance in applying those skills to their
specific situations,” he says.
Today, Kozlowski uses only SFBT with
clients, but he insists that choice does
not make him rigid in his practice. “We
have a saying in solution-focused brief
counseling: ‘If it isn’t broken, don’t fix it. If
it works, do more of it. If it doesn’t work,
stop doing it. Do something different.’
Under this motto,” he says, “it’s possible
to integrate almost any approach within a
brief model.” u
Getting started
For those wanting to learn more about
integrating SFBT into a counseling
practice, Trammel recommends reading the
works of de Shazer, Erickson, Berg and Bill
O’Hanlon. In addition, many continuing
education opportunities are available online
and through the Solution-Focused Brief
Therapy Association (sfbta.org).
Kozlowski notes that some counselors
may be surprised to find they are already
familiar with some of the positive
Contributing writer Stacy Notaras
psychology components of the SFBT
Murphy is a licensed professional
model. He started learning about SFBT
counselor and certified Imago
during a clinical internship, assuming it
relationship therapist practicing in
would sit alongside cognitive behavior
Washington, D.C. To contact her,
therapy (CBT) and motivational
visit stacymurphyLPC.com.
interviewing in his counseling toolkit.
Instead, he found himself inspired by
Letters to the editor:
SFBT’s emphasis on client strengths.
[email protected]
“Where CBT assumes erroneous
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July 2013 | Counseling Today | 47
A counseling leader’s unlikely path
By Heather Rudow
West-Olatunji scales the Great Wall
on a day off after providing disaster
mental health training to practitioners
in the Beijing area.
It took Cirecie West-Olatunji several years and several job changes before she discovered
her calling as a professional counselor, but now she is ready to take the helm as ACA’s 62nd president
I
t’s a little surprising to find out that someone so
passionate about counseling began her professional
career as a retail associate at a Jordan Marsh
clothing store in Manchester, N.H.
Less surprising perhaps is finding out why Cirecie
West-Olatunji, who took office as the 62nd president
of the American Counseling Association on July 1,
didn’t necessarily excel in retail. “I spent my time talking
to customers about their lives and helping them solve
their problems,” she says. “I was very well known by
the customers, but I wasn’t very good” at being a retail
associate.
Although West-Olatunji could tell she had a sense for
understanding and connecting with people, it took a few
more twists and turns down other career paths before
she eventually figured out that counseling was the right
profession for her.
“I’ve lived two or three lives already,” jokes WestOlatunji, an associate professor and director of the
counseling program at the University of Cincinnati, as
well as director of the university’s Center for Traumatic
Stress Research. She has a daughter, Ayana, who has a
master’s degree in education, and a son, Malcolm, who
is working in the Peace Corps after graduating from
Morehouse College.
A native of Albany, N.Y., West-Olatunji was the fourth
child and first girl in her family. She spent a lot of time
with her older brothers growing up and is still very close
with them. “I was always trying to keep pace with them,”
she says. “This may account for my drive and ambition. I
am always trying to keep up.”
During the first five years of her life, West-Olatunji’s
parents had extended family come live with them on
the second and third floors of their home. “I think this
experience served as a foundation for my community
mental health and outreach work,” West-Olatunji says.
“I am very comfortable with large groups and understand
intersystemic dynamics.”
West-Olatunji believes her interest in multiculturalism
and social justice also began in childhood. “I was always
doing community service, participating in the March of
Dimes,” she says. “My mother always thought, ‘What
a weird kid’ [on account] of all the community service
I loved to do, but I don’t think I had the words to really
talk about those things [yet]. I understood people were
having difficulty on the outside and I was supposed to
help them, but I didn’t have enough knowledge.”
West-Olatunji grew up in a working-class family but
says her parents “had a vision for their children and
made it a reality. All five of us have been successful in
our careers. Two of us are Ivy League graduates, with
two other siblings having graduated from Stanford and
Southern Illinois University. There are two Ph.D.s among
us and one M.F.A. Two of us joined the professoriate, one
became an engineer, one a clinical psychologist and one a
computer technologist.”
After leaving behind retail life at Jordan Marsh, WestOlatunji’s next “life” entailed working as associate director
of admissions at Worcester Polytechnic Institute in
Massachusetts. “I started at a time when there were not a
lot of females or a lot of people of color in that industry,
and I wanted to be a part of that,” she says. “I loved what
I did.”
West-Olatunji was responsible for creating and
directing the school’s minority admissions program as
well as its advocacy efforts. Eventually, however, she says
she realized “there was something missing, and I didn’t
know what that was.”
So, for a brief time, West-Olatunji tried her hand
selling mutual funds at a securities firm in New York City.
She jokes that her reasoning for pursuing a high-pressure
career in a fast-paced city then notorious for its unfriendly
people was to force herself to “harden up.”
West-Olatunji found the city’s tough reputation to
be at least partly undeserved, however. “I met all these
wonderful people who were so sweet,” she says. Even
so, she soon figured out that although she was enjoying
herself, she was not selling mutual funds fast enough.
Finding a ‘home’ for her skills
West-Olatunji next took a position as the assistant
director of special educational programs at the Albert
Einstein College of Medicine in the Bronx. It was there,
she says, “where it happened.” She found her calling to
become a licensed professional counselor.
Her main purpose at the Albert Einstein College of
Medicine, a graduate school of Yeshiva University, was
to provide support to students and ensure that they had
all the tools necessary to be successful. In her role, she
noticed the college’s nontraditional students — students
who were older or from multicultural backgrounds or
foreign countries — had the most trouble flourishing. In
searching for reasons why these students were struggling,
West-Olatunji participated in the annual roundtable held
by the Teachers College of Columbia University, which
focused on multicultural counseling.
Subsequently, she tailored the curriculum to meet
the needs of the nontraditional students at the medical
college and provided them with interventions. It was
then that her desire to become a licensed professional
counselor was fully realized.
“I thought, ‘This explains a lot. This is my home.
This is what I’ve been looking for in the 10 years since I
graduated,’” recalls West-Olatunji, who had earned her
bachelor’s degree from Dartmouth College in 1977 while
majoring in drama.
July 2013 | Counseling Today | 49
She left her position at the medical
college in 1992 to attend graduate school
at the University of New Orleans, where
she secured a master’s degree in 1994 and
a doctorate in 1997, both in counselor
education. She then took a position as
assistant professor and director of the
counselor education program at Xavier
University of Louisiana.
Kimberly Frazier was one of WestOlatunji’s first master’s students and
research assistants. Her teacher and
mentor’s passion for the counseling
profession inspired her. “Cirecie was so
excited about the counseling profession
and being a professional counselor. It was
infectious to anyone who came in contact
with her,” recalls Frazier, the Association
for Multicultural Counseling and
Development’s (AMCD’s) representative to
the ACA Governing Council. “I remember
thinking, ‘I hope I give my students half
of the excitement and passion, because her
energy and passion is literally nonstop.’”
Frazier predicts that West-Olatunji’s
“ability to serve as a calming force and
mediator for those who may not see or
value a viewpoint opposite of the other,”
combined with her love of what she does,
will make her an excellent ACA president.
As was true with West-Olatunji’s decision
to become a counselor, however, her foray
into counseling leadership would not occur
immediately. In fact, it would require
outside encouragement.
Getting involved at a national level
As a member of the Louisiana Counseling
Association, West-Olatunji served as editor
of the Louisiana AMCD’s newsletter. She
also loved being a member of ACA and
encouraged her students to join, but at that
point, she says, she “didn’t see the need to
run for major office. I just enjoyed being a
part of the local branch operations.”
It was only after light pressuring from
the late Victor Bibbins, a former president
of AMCD and a coeditor of Multicultural
Competencies: A Guidebook of Practices, that
West-Olatunji decided to run for national
office. Bibbins eventually became a mentor
to West-Olatunji. She believes he saw in her
what she describes as “a passion in whatever
I do. I try to give everything my all. I have
a sense of integrity, and I try to instill that
leadership development in my students.”
Edil Torres Rivera, a professor at the
University of Florida and a former president
of both Counselors for Social Justice and
AMCD, witnessed those characteristics
50 | ct.counseling.org | July 2013
firsthand when he and West-Olatunji were
colleagues at the University of Florida.
“As a person, she is very charismatic and
caring. She cares about her students and
profession beyond the call of duty,” Rivera
says. “As a professional, she is the ultimate
counselor educator. She walks the walk
and takes students on a journey [to] the
multicultural and social justice roots of the
counseling profession as well as the critical
lessons of what an effective counselor is and
why we need to be the most informed of all
professionals.”
Though slightly apprehensive, WestOlatunji followed Bibbins’ advice and was
elected vice president of African American
affairs for AMCD. “I learned a lot about
[AMCD],” she says, “and that really opened
my eyes to issues that we face as counselor
educators and counselors, and raised the
question of, ‘How do we advocate for the
profession?’ I discovered that leadership
allows us to collaborate on policy that
advocates for the profession. What excited
me was the idea that I could advance
counseling as a profession [at the national
level]. I could see the big picture, whereas
before I was just thinking at a state level.”
Thrilled by this newfound experience
and influence, West-Olatunji was content
to remain in her role as vice president. Her
mentor had other plans, however.
In the same gentle, persistent manner he
had used before, Bibbins suggested WestOlatunji run for president of AMCD. After
she was elected president for the 20072008 term, Bibbins next proposed she
seek office as AMCD’s Governing Council
representative for 2009-2010. Not only was
West-Olatunji once again elected, but ACA
then-President Lynn Linde also selected her
to serve on ACA’s Executive Committee.
When Bibbins passed away in 2010,
West-Olatunji was incredibly saddened
to lose a mentor she cared about and
respected. But there was also a slight sense
of relief. “He always kept pushing me to
do more [at the national level],” she says.
“Now I felt [like I could say], ‘I’m truly
done. I can move on to other things.’”
But as it turns out, Bibbins wasn’t the
only one who had taken notice of WestOlatunji’s potential. Past presidents of ACA
began telling her they thought she had the
skills and personality to lead the world’s
largest association dedicated to representing
professional counselors in various practice
settings.
“All I kept thinking was, ‘Who is this, the
spirit of Victor Bibbins?’” West-Olatunji
says with a laugh.
She eventually agreed to be nominated
to run for ACA president and then “didn’t
think about it anymore,” she says. “I didn’t
think I would win. People run several times
for this position, so my thought was, ‘I’ll
get out of this because it’s so rare people get
elected their first time running.’”
When she received a phone call from
ACA Executive Director Richard Yep and
Past President Marcheta Evans informing
her she had won, West-Olatunji was
shocked. “I almost fainted,” she says.
Spelling out a vision
That initial shock eventually wore off
and, today, West-Olatunji finds herself
very much looking forward to her time
as ACA president. One area she would
like to focus on during her presidency
is internationalization of the counseling
profession.
“To me, ACA’s involvement in
internationalization efforts means that
members of our organization collaborate
with members of our sister organizations
throughout the globe to provide clinical
services, conduct research and develop
policy that affects us all,” she says.
“Additionally, internationalization means
that we share knowledge across countries
to provide the most effective services and
advance the profession. As a result of these
activities, I believe that counseling will
become more recognized globally, more
counseling organizations will be created
internationally and we ... will see the value
of adopting effective practices that emanate
from outside of the U.S.”
“As an organization, we’ve been moving
toward internationalization in counseling
across several presidencies,” West-Olatunji
continues. “We’ve dabbled a little, but
I want to take one concrete step. It’s
important for counselors to know what
counseling looks like in other countries.
I’ve already been doing a lot of work
internationally, and I’m bringing a lot of my
resources from the international arena into
my presidency. “
West-Olatunji has conducted multiple
international outreach trips and provided
consultations in South Africa, Romania,
Botswana, Malaysia, Japan, China,
Singapore, Malaysia, the Philippines,
Thailand, Korea, India, Western and
Eastern Europe, and the Americas to help
advance the counseling profession. She
has also provided disaster mental health
counseling services or training in the Pacific
Rim, Botswana, South Africa and Haiti.
“I’ve had the opportunity to be in a lot
of places working with a lot of practitioners
who are looking at the advancement of
counseling,” she says. “Now we are at the
point where we are asking where we need
to go [with the] internationalization of
counseling, what can ACA do to help, and
how can we do it in a way that benefits us?”
West-Olatunji also would like to focus
on leadership development. “In my time as
Governing Council representative and as
ACA president-elect, I received leadership
training from the American Society of
Association Executives [ASAE],” she says.
“One of the things that became very clear
to me is that our Governing Council is not
operating optimally, and [doing so] would
help us a lot.”
She thinks having ACA Governing
Council members learn best practices for
being a board member would make the
organization stronger. “One of the pitfalls
for us is that many of us are counselor
educators. We are very good at the things
that we do, but we may not know a lot
about boards and nonprofits and how they
operate,” West-Olatunji explains.
In addition, West-Olatunji would like
to promote increased social action on the
part of ACA members. “Even with all the
discussion of advocacy and social justice
within counseling,” she says, “on a grassroots level, students and counselors are still
asking, ‘What does that look like? What are
the skills I’m supposed to have that should
reflect social justice?’”
West-Olatunji would like to do more to
teach the characteristics of social justice and
social action by adding practitioner voices
in blog posts and reinstating multicultural
training for members.
Rachael Goodman can attest that WestOlatunji is the perfect person to head such
efforts. Goodman says her awareness and
knowledge of cultural and social justice
issues increased greatly while she was a
master’s student in the counseling program
at the University of Florida under WestOlatunji.
“[West-Olatunji] shared her own
experiences with injustice and inspired me
to be more reflective about my own cultural
background and experiences of privilege
and marginalization,” Goodman says. “She
instilled in her students a commitment to
multiculturalism and social justice, which
West-Olatunji takes a break from leading ACA’s People to People delegation in India.
is critical to ethical and effective counseling.
As ACA president, I anticipate that she
will bring this important framework to the
entire profession to move ACA forward.”
In class, West-Olatunji often selfdiscloses and shares her experiences as an
African American female in a race-based
society. “Even though my life reflects some
successes, I have experienced many of the
same microaggressions that other culturally
and socially marginalized women face in
the U.S. Both institutional and individual
racism have had their effect on me,” she
says. “Fortunately, I have had some very
knowledgeable and resourceful mentors —
male and female, African American and
non-African American — who have helped
me to stay focused.” Right where she belongs
West-Olatunji knows her path to
becoming ACA president is not the typical
one. “I was not the person who knew
exactly what to do after graduating college,”
she says. “It took me awhile to find myself,
what matched my personality, my passions
and my beliefs.”
But now that she is here, West-Olatunji
looks forward to using her year as president
to make a difference in as many ways as she
can.
“I’ve found that I am very passionate
about service and giving service to
organizations,” she says. “That is what
counseling has done for me. It has
contextualized that not only can I give what
I have to offer, but others can receive it in a
positive way.” u
Heather Rudow is a staff writer for
Counseling Today. Contact her at
[email protected].
Letters to the editor:
[email protected]
July 2013 | Counseling Today | 51
Knowledge Share - By Michelle J. Cox
Taking the lock off the
Spiritual Integration Toolbox
Clinicians sometimes need to be reminded that religion and spirituality are
important dimensions in counseling regardless of the presenting problem
S
tudents in counselor education
courses often ask what special
training they need to counsel
clients with spiritual issues. I ask these
students to consider what course content,
prior employment, life experience or other
education might prepare them to address
religious or spiritual themes. Some report
they would rely on pastoral training or
personal experiences in specific religious
denominations. Others mention required
diversity courses but are unsure whether
all of the world religions can be covered
properly in depth. A few students note selfperception of religious experiences (both
healthy and unhealthy) and wonder about
imposing values.
I usually follow up these students’
comments by posing the same question
about different presenting problems. What
specialized training might they need to
assist clients with communication issues,
addictions, sexual dysfunction or anxiety?
The room always goes silent as they ponder
the true nature of my question. Some
diagnoses — for example, eating disorders
and personality disorders — are so difficult
to treat that they require specialized training
even after obtaining a master’s degree. But
the perception that religious or spiritual
issues are somehow different than most
other presenting problems limits clinical
engagement in this important aspect of
well-being.
Graduate students in the mental health
field gradually develop knowledge and
skills that can lead clients with unhealthy
thoughts, behaviors and emotions
toward change. New counselor education
graduates are not expected to be experts
immediately. Rather, they experience
tremendous professional growth during
their prelicensure, supervised experience.
The students’ concern over their level of
religious or spiritual expertise challenged me
to consider what expectations I convey as an
educator. Furthermore, I wondered why the
question about spiritual expertise arose so
often in comparison with the other topics
counseling students study.
Those classroom discussions and the
questions that followed led me to conduct
four years of empirical research. In my
research, I evaluated the content taught
in CACREP-accredited institutions as
compared with that of private, religiousbased programs; the differences between
what educators in private, religious-based
programs thought they were teaching
and what the students reported being
taught; and master’s-level students’
perceptions of a transcendent other as
related to attachment style.
On the basis of these and other studies,
in addition to an extensive literature review,
awareness of pedagogical assumptions
about counselor education and student
anecdotes, the Spiritual Integration Toolbox
was born. As a former steel fabricator with
years of project management experience,
the toolbox seemed an apt metaphor. The
conceptualization of specific counseling
skills and knowledge as tools helps me to
convey their importance in a unique way.
Intake and assessment
Religion and spirituality (RS) are
important dimensions in counseling
regardless of the presenting problem.
RS issues may or may not be addressed
in treatment depending on stated client
goals, but information about RS should
be collected upon intake just as clinicians
collect information on sociodemographics,
family history, development, attachment,
symptoms, mental health history, medical
information, educational experiences,
July 2013 | Counseling Today | 53
career background, legal issues and social
relationships. Proper use of spiritual
integration tools assumes:
n Basic knowledge of the differences
between religion and spirituality
n
An awareness of ethical and legal responsibilities to incorporate client RS
concerns in assessment, diagnosis and
treatment planning
n
A general understanding of the potential harm to clients when clinicians
impose their own values
The first requirement for integrating
spiritual issues into counseling is the
choice of toolbox: a proper RS intake.
Intake is a facilitated process rather than a
product, and it helps carry the clinician’s
understanding of client RS history
throughout the clinical relationship.
Much like a portable toolbox that carries
integral tools from a larger tool chest,
specific RS questions should be chosen to
elicit discussion about RS experiences and
changes, familial or relational pressure,
trauma or abuse (all types), influence of
RS cultural identity, self-awareness, image
of a transcendent other, perception of a
relationship with a transcendent other,
and current feelings, cognitions and
behaviors.
Clinical assessment is the most
complicated tool in the box. Its use
will be limited by how much research
clinicians want to conduct and how
much training clinicians receive before
using it. These assessments function as a
level in a clinician’s toolbox. Contractors
know that levels can be used to
determine grades and elevation changes,
turn rough angles, lay out building
foundations, set forms, level walls, and
set lines and stakes. Likewise, specific RS
assessments allow clinicians to balance
qualitative RS information collected
via verbal or written intake with valid
and reliable empirical data. A variety of
valid and reliable RS assessments can
measure attitudes, beliefs, engagement,
satisfaction, maturity, wisdom, knowledge
or confidence in particular faith systems,
as well as how RS issues affect clients
relationally and how the image of a
transcendent other relates to attachment.
For example, John Ingram and Ed
Sandvick’s Holy Spirit Questionnaire
(1994) was designed to measure perceived
knowledge of the Holy Spirit. This tool
54 | ct.counseling.org | July 2013
helps assess client content, language and
perception. Craig Ellison and Raymond
Paloutzian developed the Spiritual WellBeing Scale (1982) to assess the spiritual
dimension of the subjective state of wellbeing, including vertical and horizontal
dimensions. The vertical dimension refers
to a sense of well-being in relationship to
God. The horizontal scale is the overall
sense of life purpose and satisfaction.
Lest clinicians assume assessment
tools are available only for clients of
the Christian faith, Todd Hall and
Keith Edwards designed the Spiritual
Assessment Inventory (1996) to measure
five spiritual maturity factors: awareness,
realistic acceptance, disappointment,
grandiosity and instability. Internal
consistency is high and construct validity
is good. This instrument also contains a
lie scale.
The Francis Scale of Attitude Toward
Christianity (FSAC, 1978) measures
attitudes on religious values. Its items
emphasize a unidimentionality of religion
rather than focusing on religious lifestyle
behaviors such as worship attendance.
Therefore, there is evidence that the
scale is valid and reliable in measuring
attitudes toward Christianity, Hinduism,
Islam and Judaism. Phra Nicholas
Thanissaro’s amended FSAC (2011)
demonstrated internal consistency,
reliability and validity with Buddhist and
Sikh populations.
Kim Bartholomew and Leonard
Horowitz designed the Relationship
Scale Questionnaire (1991) to evaluate
orientation to close relationships,
noting that the language of each of the
30 items could be reworded to suggest
a specific type of relationship such as
significant other or relative. In 2010,
David Manock and I amended the
items for RS assessment by changing
the stems to read transcendent other. We
found strong reliability and validity,
internal consistency, construct validity
across a variety of faith systems and also
correlation to attachment style. Using an
assortment of these types of instruments
will add depth to the clinician’s
understanding of client RS concerns.
Diagnosis and treatment planning
What happens after all this assessment?
My husband likes to work on cars in his
spare time. He keeps a tool in his portable
toolbox that reads engine codes. Those
codes help him identify problems noted
by the car’s computer system and tell him
what parts to repair or replace. Similarly,
diagnostic codes enable clinicians to
identify specific symptoms and determine
the course and prognosis of specific
illnesses and issues. Understanding which
diagnostic codes in the Diagnostic and
Statistical Manual of Mental Disorders
(DSM) correlate most often with RS
issues hones the clinician’s focus.
Diagnosis related to RS issues can
be made using a V code for religious
or spiritual problems alone, as a
complication to other diagnoses or as
a comorbid disorder. Thus, problems
or concerns related to RS issues should
be diagnosed using the V code and
then addressed in treatment planning.
Pay close attention to the possibility of
comorbid or co-occurring disorders.
Research has demonstrated correlation
in both diagnosis and treatment between
RS problems and posttraumatic stress
disorder (PTSD), addictions, sexual
dysfunction and disorders, mood
disorders (specifically major depressive
episode and the postpartum subtype),
anxiety disorders, sleep disorders and
bereavement.
Once diagnosis occurs, accurate
treatment planning takes priority.
Contractors rely on guides called
construction masters when tackling
building projects (though the texts
are often found on the floorboards of
trucks rather than in toolboxes). These
guidebooks detail the correct way to
accomplish tasks, from determining
proper rise and run of stairs to measuring
the amount of concrete necessary
to pour a pad. There are many right
ways to design treatment plans, but
certain key elements must be present:
collaboration with clients in establishing
goals, alignment of interventions and
homework with measurable outcomes,
and continuity throughout. Continuity
means the client’s report of symptoms
relates to diagnostic criteria. Diagnostic
criteria lead clinicians to a diagnosis
and prognosis. Proper diagnosis and
understanding of prognosis lead to
relevant goal setting. Relevant goals
lead to accurate choice of interventions.
Accurate interventions lead to clear
outcome measures. Clear outcome
measures lead to awareness of
treatment. As with all interventions,
they should be utilized in service toward
improving treatment outcomes.
effectiveness. Awareness of effectiveness
leads to engaging and dynamic treatment.
This type of evidence-based continuity in
treatment planning is what I term elegant
design.
Interventions
Imagine designing the most elegant
treatment plan possible and then getting
to the intervention column without
the tools to facilitate the RS changes
necessary for client growth. So far, you
have chosen a nice toolbox (intake),
included a level (assessment instruments),
and referred to your construction
master (the DSM). Interventions are
the remaining tools that clinicians use
to effect change — to do the work
of counseling. Clinicians need a full
bag of tools, yet they often get stuck
when designing interventions because
they confuse pastoral counseling with
counseling for RS issues. Pastoral
counselors concern themselves with
spiritual growth within a specific religion
in addition to overall mental health.
The inclusion of RS issues in counseling
assumes that spiritual growth may occur
as mental health improves, but it does
not limit the client to growth consistent
within a specific faith system or religion.
Furthermore, useful RS interventions
assess the psychology of RS experiences
rather than the rightness or wrongness
of spiritual beliefs. Thus, most clinical
interventions can be adapted for RS
issues. The types of interventions most
researched include:
n RS prayer, meditation or centering
(compass)
n
RS reading or film review
n
Teaching RS concepts related to
well-being as presented in existing
Michelle J. Cox
literature, such as the differences
between religion and spirituality
(how-to manuals)
n
RS engagements and activities
n
RS journaling and writing assignments
(screwdriver)
n
In-session confrontation or challenge
about incongruent RS beliefs
(hammer)
n
Exploration and adjustment of RS
language and concepts (wrench)
n
Review of attachment images related
to RS experience
n
Projective techniques (laser)
Interventions for RS issues should be
related directly to the client’s presenting
problems, stated goals, interests or
complications affecting success in
Case study
Now comes the fun part — application.
Rosa is a 27-year-old Hispanic female
working in retail sales in a big box store.
She presents for individual counseling
for PTSD symptoms 10 months after
the death of her twin sister in a car
accident. Although the accident was
not Rosa’s fault, she was driving when
the accident occurred. She was seriously
injured and could not attend her sister’s
funeral. Rosa reports experiencing
hypervigilance, nightmares, hopelessness,
depersonalization, an impending sense of
doom and flashbacks since she awoke in
the hospital after the accident. She says
she feels “guilty about everything,” from
her sister’s death to misplacing simple
items at work or home. She also states
she “is angry at God for taking her sister”
rather than taking her or both of them.
Regarding family history of mental
illness, Rosa says she is unaware of
any diagnosis on either side or her
family. She reports, however, that her
mother behaved as though she were
depressed and neglected Rosa and her
siblings. Indeed, Rosa describes living
in a multigenerational household and
caring for her elderly grandparents and
younger siblings because her mother was
often absent without explanation. Rosa’s
father was never involved in her life.
Rosa also describes some enmeshment
between her and her twin sister, saying
they still dressed the same way up until
the accident. Rosa reports relying heavily
on her twin for emotional support after
experiencing a date rape at age 16. She
July 2013 | Counseling Today | 55
states, “My sister protected me, kept
men away for years and recently began
choosing men for me to date to help me
get past the assault.”
Prior to the accident, work and career
boosted Rosa’s self-esteem. She had
succeeded in school despite years of
academic struggles after being diagnosed
with dyslexia at age 14. She worked her
way up to department management at
her store in only four years but reports
concern that she will now lose her
job because of excessive absences and
scenes she has created recently at the
store. She acknowledges having several
“panic attacks” and screaming in terror
after being startled by a loud noise or a
customer approaching her from behind.
Rosa describes her Catholic faith as
“foundational” in her development but
states, “I refuse to go to church anymore.”
Although she admits feeling guilty about
that and “missing my church family,”
she reports feeling angry with God. She
also describes having “my own version
of religion.” She explains that multiple
friends videotaped her sister’s funeral and
created a montage of video clips for her.
While watching the video almost daily,
Rosa prays and talks to her sister, asking
her for guidance and advice. Her stated
goals in counseling include a reduction of
“panicky feelings,” a sense of control over
her hypervigilant behaviors, a decreased
sense of guilt, and restoration to and
relationship with her faith and church
family.
In addition to this verbal intake
information, Rosa completed the
Spiritual Well-Being Scale, the Spiritual
Assessment Inventory and the modified
Relationship Scale Questionnaire. These
instruments confirmed and detailed
attachment issues projected onto Rosa’s
image of God, her sense of abandonment
and fear of intimate relationships, all
related to RS experiences. Rosa was
diagnosed with PTSD, bereavement and
religious or spiritual problems. Among
other interventions, treatment included:
n Repeated use of the Instant Calming
Sequence (ICS) for centering and
relaxation to reduce anxiety (later
supplemented with prayer)
n
Client journaling about feelings of
panic to identify triggers
56 | ct.counseling.org | July 2013
n
n
Projective techniques using play dough
and sand tray to identify and express
issues of attachment, shame and guilt
Step-by-step reengagement in faithbased activities that encouraged
feelings of safety and socialization
Robert Cooper designed the ICS
(2003) as a six-step process to help
change the brain’s and body’s reaction to
stressful situations. The six steps seem
simple, but when practiced consistently,
they provide clients with a sense of
control over anxiety symptoms. The steps
are controlled breathing, smiling, positive
posture, relaxation, facing reality and
taking control.
The prognosis for treatment of PTSD
alone is challenging because Rosa waited
10 months before seeking treatment.
Furthermore, when issues regarding social
support, childhood neglect, family history
of mood disorder, and preexisting trauma
complicate PTSD, full remittance of
symptoms is unlikely. Thus, identifying
all comorbid diagnoses is important for
Rosa’s treatment. Helping Rosa through
RS issues and bereavement is necessary
for reduction of PTSD symptoms if full
remission is not possible.
Rosa’s willingness to engage in
projective RS interventions seemed
key to her success. They allowed her to
examine how misperceptions embedded
by her young experiences and absence of
attachment interfered with her image of
God. She chose to work hard to create
new relationships within her chosen
faith system, which were healthier
examples than what she was exposed to
during her youth. These healthier social
relationships provided much-needed
emotional support and also allowed her
to understand her enmeshment with her
sister. Once she understood and released
her unhealthy reliance on her twin, she
was able to grieve, unencumbered by the
idolization that previously had buried
her in guilt. Though some flashbacks,
sleep disturbance and sensitivity to sound
triggers still exist, Rosa reports feeling safe
and having hope for the future. She is
even dating again.
Effective treatment for RS issues is
not reliant upon religious knowledge,
theological training or years of
engagement in a particular faith system.
Indeed, too much knowledge can often
become a barrier in treatment when
clinicians begin to feel expert about
RS issues. Rather, a willingness to
evaluate the psychological impact of RS
experiences — to fully engage in the
client’s RS world — allows clinicians
to conceptualize how RS issues become
embedded in other symptoms and
diagnoses. Identifying and treating RS
issues can enhance clinical work and
promote holistic healing. The Spiritual
Integration Toolbox is simply a reminder
that clinicians already have the tools
necessary to do this important work. u
Knowledge Share articles are
adapted from sessions presented
at American Counseling
Association conferences.
After six years of teaching in
counselor education at George
Fox University and a year as the
director of Student Health and
Counseling at Western Oregon
University, Michelle J. Cox is
currently home on leave caring
for her terminally ill husband. She
provides mental health consulting
services online to individuals,
families and organizations seeking
to integrate medical, mental
health and spirituality into holistic
treatment planning for those
struggling with mental illness. She
spends ample time writing and
recording the progression of her
husband’s early-onset dementia
and its impact on the family.
She is also training their three
Australian shepherd puppies to
become therapy and service dogs
for her husband. Contact her at
[email protected].
Letters to the editor:
[email protected]
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NCDA Conference
July 8-10
Boston
Celebrate 100 years of the National
Career Development Association. The
conference includes a series of memorable
anniversary events, comprehensive
professional development institutes,
special tours, featured speakers and rich
learning experiences. Career counselors
and specialists will share best practices
and ideas, examine new programs and
products, and have the opportunity
to network with leaders in the career
development field. Pre- and postconference
CE opportunities will be held July 7 and
July 10. Boston was home to many of
the founders of the National Vocational
Guidance Association (the former name
of NCDA), so it is fitting that we return
“home” to celebrate the association’s 100th
anniversary. For more information, visit
ncdaconference.org.
AADA Summer Conference
July 18-19
New York City
The Association for Adult Development
and Aging’s 2013 summer conference
will be held at the Roosevelt Hotel in
Manhattan. The theme is “Adult Identity
Evolution: Diversity Within Personal and
Professional Transitions.” On Thursday
there will be two preconference workshops:
Quinn Pearson of the University of
North Alabama will address supervision,
while Harriet Glosoff of Montclair
State University and Michael Kocet of
Bridgewater State University will focus
on professional ethics. Presentations
addressing a wide variety of counseling
issues related to adults across the life span
will be presented on Friday. Conference
registration is available at aadaweb.org.
Preconference learning institutes are $65
or $120 for two. Conference registration
is $165 for professionals and $85 for
students.
Black Doctoral Network Conference
Oct. 3-5
Philadelphia
The Black Doctoral Network’s
conference will be held at the Doubletree
by Hilton Philadelphia Center City.
The theme is “Scholarship, Service and
Community.” Academics and activists
Cornel West, Julianne Malveaux and
William Julius Wilson have been
confirmed as session speakers. The call for
papers can be accessed at blackphdnetwork.
com/resource/resmgr/Media/BlackPhDCFP1_revised_(1).pdf. For more
information visit facebook.com/pages/BlackDoctoral-Network/166151070110252.
In addition to interdisciplinary panel
presentations, this conference will have
interactive roundtables. Professors from
various fields will converse and give
insight on the need for interconnectedness
throughout the academy and community,
the publish-or-perish dynamic and
race and gender issues and concerns.
Workshops on handling job talks,
effective/affective use of the Internet/social
media for academics and professionals,
and securing postdocs and tenure track
positions will also be addressed.
KCA Annual Conference
Oct. 23-25
Louisville, Ky.
The 2013 Kentucky Counseling
Association Conference will take place
at the Galt House Hotel with the
theme “Counseling in a World of Need:
Providing Hope and Help.” A variety of
preconference workshops are scheduled for
Oct. 23. The opening session will feature
Travis Brown, who is on his nationwide
No Bullying Tour. ACA Immediate Past
President Bradley T. Erford will keynote
the general session. The Awards Brunch
will feature motivational speaker and singer
Gary Griesser. Special programming on
a variety of counseling issues is planned
for a range of counseling professionals,
including graduate students. Registration
includes the opening reception and school
counselor and LPCC/LPCA luncheons.
For more details and registration
information, visit kyca.org.
FYI
Call for papers
The Journal of Poetry Therapy: The
Interdisciplinary Journal of Practice,
Theory, Research and Education is seeking
manuscripts on the use of the language
arts in therapeutic, educational and
community-building capacities. The
journal purview includes bibliotherapy,
healing and writing, journal therapy,
narrative therapy and creative expression.
The journal welcomes a wide variety of
scholarly articles, including theoretical,
historical, literary, clinical, practice,
education and evaluative studies. All
manuscripts will be submitted for blind
review to the editorial board. Style should
conform to the Publication Manual of the
American Psychological Association (sixth
edition). All articles must be original
material, not previously published
or soon-to-be-published elsewhere.
Manuscripts should be submitted in
electronic format (Microsoft Word) as
an email attachment to editor Nicholas
Mazza at [email protected].
Bulletin Board
submission guidelines
Email [email protected] for
submission guidelines. See box below for
upcoming submission deadlines. u
Submit your news
and upcoming events
All divisions, regions and branches of
the American Counseling Association
may submit monthly news articles of
350 words or less to “Division, Region
& Branch News.” In addition, divisions,
regions and branches are invited to
list their upcoming events in “Bulletin
Board.” For submission guidelines,
contact Heather Rudow at hrudow@
counseling.org. Be advised of the
following upcoming deadlines for
submitting items to either section.
September 2013 issue: July 25 at 5 pm ET
October 2013 issue: Aug. 28 at 5 pm ET
November 2013 issue: Sept. 26 at 5 pm ET
December 2013 issue: Oct. 24 at 5 pm ET
July 2013 | Counseling Today | 57
Reader Viewpoint - By Christie Melonson
The education of a counselor-manager
What they don’t teach you in graduate school about becoming a manager in mental health settings
Everyone who enters a graduate program
in counseling daydreams at some point
about his or her professional future. The
ultimate goal for some is to start a private
practice. For others it is to work in a certain
setting or with clients who have specific
issues or treatment needs. Many therapists
also consider expanding their repertoires
to include consulting, professional
development or even college teaching.
Graduate education seemingly can help
counselors develop all of these competencies
through course work, assistantships, service
learning and internships.
Learning about therapeutic techniques
and best practices in mental health is the
gold standard in preparation for licensure.
But being a clinical manager — someone
who supervises counselors and other mental
health professionals in a public or private
mental health setting — requires a different
skill set that is not readily addressed in
most graduate counseling programs.
Looking back, I wish that my course work
and other educational experiences had
prepared me to become a manager, leader,
trainer, organizational development expert
and advocate, in addition to becoming a
counseling practitioner.
Most counselor education works to
establish one’s identity as a counselor.
This can be a double-edged sword. On
one hand, attachment to this professional
identity ensures integrity in one’s work
as a clinician, identification with ethical
codes and association with the larger body
of professional counselors and healers. On
the other hand, the idea that one is trained
to provide therapy sometimes discourages
the individual from considering other
competencies and roles that counselors
are often introduced to when entering
the actual world of work. Granted, the
therapeutic relationship is what we are
best trained for and what most of us look
forward to in our work. But our dedication
to helping clients in their healing journeys
also involves intensive documentation,
billing, marketing for private practice,
working within a larger system, sharing
resources, and getting along with coworkers
and support staff, among other things. In
addition, the paycheck that accompanies
therapeutic counseling work is sometimes
insufficient to pay all the bills and student
loans and meet all the other needs of the
households we are trying to manage.
When I was in graduate school, I didn’t
devote any thought to the possibility
of entering the world of mental health
leadership. My ultimate goal was to obtain
my license and open a private practice. After
achieving that goal, however, I realized I
had additional hopes for my professional
future that would not be met in the context
of private practice. I became aware that
opportunities for advancement existed in
many mental health organizations. These
opportunities were more profitable than
doing therapy exclusively and were also very
fulfilling, allowing me to shape my staff and
help the populations we were serving in
various ways.
Challenges in mental
health management
The challenges are many when a
counselor takes on the role of manager in
a mental health setting. It is easy to feel
unprepared for the bumps and bruises that
take place while learning to lead others.
July 2013 | Counseling Today | 59
{
What follows are some of the areas I
have found particularly challenging as a
manager working in mental health.
When a counselor enters
a management and
leadership role, he or she
must become familiar
with the organization’s
culture and learn to
operate within that
belief system. This often
requires significant
adjustment and change.
{
Managing employees
I don’t remember learning how to
effectively manage employees in my
graduate counseling program. It has
been one of my biggest challenges.
Sometimes we assume that simply having
a supervisory title or being called “the
boss” will speak for itself. This is referred
to as legitimate power in the leadership
literature.
Many counselor-managers also
assume that because of their employees’
backgrounds as clinicians, these
employees automatically will be
cooperative, be willing to express
concerns and contribute ideas to improve
what is happening in the workplace.
Unfortunately, employees do not manage
themselves. Managers must sometimes
intervene to ameliorate problems and
streamline the organizational structures
that are already in place. While paying
attention to licensure standards, managers
must also interpret organizational rules as
well as the unspoken rules of engagement
in the workplace. For example, some
mental health organizations encourage
clinical managers to take an authoritarian
approach to leadership and not take
“excuses” from clinicians who are unable
to reach quotas for billable hours. In
another mental health organization,
however, the clinical manager facing this
issue may be encouraged to conduct a
focus group with his or her clinicians to
find innovative solutions to increase client
contact hours.
delivered and measured. With the push
for integrated health care and evidencebased practices, counselors can be caught
off guard when there is no option for
them to provide their preferred treatment,
when treatment modalities and number
of sessions are dictated by the funding
source, and when they are introduced to
billing. The manager of these counselors
needs to understand quality assurance
and improvement, performance
minimums and budgeting. In addition,
the manager must coach employees in all
of these areas.
Specialized programs with grant
funding require the counselor-manager
to understand all laws and rules relating
to the funding source as well as internal
organizational procedures. This can be
overwhelming for a first-time leader who is
unfamiliar with the organizational politics,
financial reporting procedures or best
practices in data collection and analysis.
Teaching and leading
Little did I know when I began my
management role in mental health that
teaching and leading were synonymous.
I learned that role modeling, reflection,
experiential learning and goal-setting —
the same techniques we use with clients
— must also be used with employees,
and that I was expected to understand
and develop the talents of my employees.
By the same token, I have also learned
that I need to continually learn from my
employees. They are the front-line service
providers and possess valuable insights
that can improve what we do as a cohesive
unit. I have also learned to learn from
60 | ct.counseling.org | July 2013
my mistakes in the work setting through
purposeful reflection and mentoring from
my superiors.
Organizational culture
According to Edgar Schein, each
organization has its own culture that
includes artifacts, values and tacit
assumptions. On the surface, symbols
that represent the organization are visible
and recognized by members of the
organization, while at the deepest level,
assumptions and beliefs exist that drive
what is considered appropriate or taboo.
When a counselor enters a management
and leadership role, he or she must
become familiar with the organization’s
culture and learn to operate within
that belief system. This often requires
significant adjustment and change. A big
part of any mental health organization’s
culture is how clients and clinicians are
treated, and the counselor-manager needs
to be aware of this. Advocacy is one of the
values imparted in counselor training, but
it is not always easy to implement in the
organizational setting.
Managed care, grant
funding and budgeting
Funding sources often dictate the
groups of clients the organization can
serve and how treatment is planned,
Multicultural issues at all levels
Managers often face concerns in
mental health organizations regarding
who is being served, who is in charge
and who should be hired. There is a need
for diversity of all kinds in leadership,
mental health administration and
research. With a rapidly diversifying
population, the United States is facing
numerous challenges associated with a
lack of ethnically and otherwise diverse
leadership. If diversity is absent in mental
health management and leadership,
the beliefs and perspectives of those
populations currently underutilizing
mental health services (even with
insurance) will not be acknowledged.
I have committed to researching this
issue as part of my efforts to advocate
for mental health services that support
everyone’s needs.
Torn loyalties
Last but not least, a paradox exists in
being both a clinician and a manager
in mental health settings. Sometimes
your inner clinician knows a certain
course of action would be best for the
clients served by your staff members. But
directives from higher-ups, organizational
loyalty, staff concerns or any number
of other things can interfere with your
programmatic goals for the clients. The
inner clinician aspires to be reasonable
with a counselor-employee who is
not making minimum contacts with
clients. The hope is that if you approach
the employee with your concerns,
he or she will magically increase the
number of billable hours, therefore
improving performance from a business
perspective. But the inner leader knows
that the organization expects you to
deliver a write-up and a warning about
termination to the employee.
Future directions
It would be beneficial if graduate
counseling programs offered mental
health leadership courses to inform
students about the full array of careers
in mental health and the variety of
leadership and administrative roles
that exist in a variety of settings. More
career education is also needed on how
to advocate for the rights of clients and
employees as well as legislation that
supports mental health service funding.
Graduate students should be given
the opportunity to seek electives or
additional training in the areas of
management/ leadership, organizational
psychology, health care law and human
resources. Aspiring professionals in
graduate programs would also benefit
from ample opportunities for research
and shadowing to more accurately
portray the realities of careers in mental
health management and leadership.
Learning opportunities that increase
understanding of the management,
business and legal aspects of mental
health leadership would help prepare the
newest generation of counselor-leaders,
who are very much in demand in the
world of mental health today. u
Christie Melonson is a licensed
professional counselor and
consultant in San Antonio. In
addition to being a manager
with the Center for Health Care
Services Head Start Mental
Health Program, she has a small
private practice and is a doctoral
candidate in education at the
University of the Incarnate Word.
Contact her at melonson@student.
uiwtx.edu.
Letters to the editor:
[email protected]
ACA-ACES
Syllabus Clearinghouse
Need Help Planning
Your Fall Syllabi?
Visit the ACA-ACES Syllabus Clearinghouse
From a recent member email ...
“I’ve used it a couple of times for reference; not just for
tests, but also for assignment ideas, course policies, reading load (if included), course descriptions, and so on.
I’m new at full-time teaching, so I’m VERY grateful for the
shared wisdom there. ”
Here are a few examples of what you will find:
n
Thomas Blum, Oakland University
- Introduction to Family and Couple Counseling
n
Kathryn MacCluskie, Cleveland State University
- Laboratory in Counseling Skills
n
Kathleen Fallon, The College of Brockport, SUNY
- Self in Society
- Counseling Concepts
n
Harriet Bachner, Pittsburg State University
- Techniques of counseling and psychotherapy
- Theories and techniques of family therapy
Visit and/or contribute today. You can find the clearinghouse under the Knowledge Center at counseling.org. All
may contribute, only members may download.
Questions or comments? [email protected]
July 2013 | Counseling Today | 61
Opinion - By Elaine Johnson, Larry Epp, Courtenay Culp, Midge Williams & David McAllister
What you don’t know could
hurt your practice and your clients
62 | ct.counseling.org | July 2013
Implications of CACREP-only language in emerging policies
A
re you a mental health counselor?
If so, you may be only vaguely
aware of the ways in which
CACREP (Council for Accreditation
of Counseling and Related Educational
Programs)-only language in hiring,
credentialing and reimbursement
policies could impact your practice. As
practicing mental health counselors and
board members of the Maryland and
Massachusetts chapters of the American
Mental Health Counselors Association,
we have watched recent developments
with increasing alarm. Our practices and
livelihoods are under serious threat, and the
public faces greatly reduced access to care,
by growing efforts to restrict the practice
of mental health counseling to those who
attended CACREP-approved graduate
programs. It is imperative that professional
counselors everywhere understand these
developments and take action to protect
what we have worked so hard to achieve —
our right to practice independently.
The hidden threats to practice
TRICARE is the health care program
for all active-duty and retired military
personnel and their families. Licensed
mental health counselors have served this
population for many years but could do so
only with physician referral and supervision.
“Interim” regulations issued in 2011, based
on a study by the Institute of Medicine
(IOM), created a new classification of
TRICARE providers (TRICARE certified
mental health counselors, or CMHCs) who
are allowed to practice independently. An
interim period was created, during which
current providers could ostensibly move to
independent status by taking the National
Clinical Mental Health Counseling
Examination (NCMHCE) and meeting
supervision requirements. The goal of the
change, according to its announcement
in the December 2011 Federal Register,
was to increase access to mental health
care by eliminating the physician-referral/
supervision requirement. Yet, the result is
quite the opposite.
TRICARE supervision rules: A
major problem lies with the supervision
requirement in the interim rule, which
states that all of one’s post-master’s
supervision hours must have been obtained
under a licensed professional counselor.
(It has come to our attention that this
rule is not being applied consistently. This
may be relieving for some, but haphazard
enforcement is not a solution to an overly
restrictive rule.) If we follow the rule, it
prohibits most of the board members of
the Maryland and Massachusetts AMHCA
chapters from TRICARE participation
because at the time we graduated, there
were virtually no counselors who could have
supervised us (since licensure laws were
relatively new). Thus, this rule disqualifies
the most-seasoned counselors in many states
from becoming CMHCs. The American
Counseling Association has requested the
removal of this stipulation (for example,
in a letter from ACA Executive Director
Richard Yep to the assistant secretary
of defense for health affairs in February
2012), but it remains on the TRICARE
application. We do not believe the IOM
intended to create a profound roadblock to
CMHC status, but efforts so far to change
July 2013 | Counseling Today | 63
the regulation have been unsuccessful.
It is also critical to recognize that at
the conclusion of the interim period in
December 2014, providers who cannot
achieve CMHC status will no longer be
able to participate in TRICARE at all
because the physician-referral provider
status will be eliminated. If you are
currently a TRICARE provider who
cannot meet this supervision requirement,
you will either terminate your military
clients or go unreimbursed — unless the
regulations are changed.
CACREP restriction in TRICARE:
The second problem with the TRICARE
rules is that once the interim period
expires, all graduates from programs not
approved by CACREP will be permanently
excluded from participation in TRICARE
even when duly licensed by their own
states. After December 2014, if you did
not graduate from a CACREP-approved
program, you cannot and will not ever be
able to join the TRICARE network.
The CACREP-only rule, in
combination with the supervision rule,
will disqualify thousands of currently
licensed practitioners. For example,
ACA’s own 2011 study found that only
13 percent of licensed mental health
counselors in New York graduated
from CACREP-approved programs. In
addition, because only 32 percent of
U.S. master’s programs in counseling
and only 11 percent of 60-credit
mental health counseling programs are
accredited by CACREP (see the 2010
text Ethical, Legal and Professional Issues
in Counseling by Theodore Remley and
Barbara Herlihy), there are undoubtedly
thousands of current counseling students
in the country who will be permanently
excluded. Again, as an example, in
Massachusetts and Maryland, 32
programs train mental health counselors.
Two (one in each state) are accredited by
CACREP.
Our country faces a critical shortage of
mental health counselors to serve legions
of our veterans, including those from the
recent wars. It is a travesty that the majority
of current and future mental health
counselors will be excluded from providing
services to these veterans. They deserve
more and better, as opposed to more
restricted, access to therapists.
CACREP-only language has moved into
regulations in other important areas:
64 | ct.counseling.org | July 2013
1) The Department of Veterans
Affairs (VA) recently created a new job
classification for professional counselors.
These jobs are open only to graduates of
CACREP-approved programs.
2) No state currently requires graduation
from a CACREP-accredited program
for licensure. Yet, CACREP’s stated goal
(see, for example, Barry Mascari and Jane
Webber’s article, “CACREP Accreditation:
A Solution to License Portability and
Counselor Identity Problems,” in the
January 2013 Journal of Counseling &
Development) is to restrict state licensure to
graduates of CACREP-approved programs.
Under regulations adopted in New Jersey
in 2006 (and ultimately reversed by the
grass-roots efforts of licensed counselors
and educators), graduation from a
CACREP-accredited program would have
become a requirement for all new counselors
in the state and any counselor moving into
New Jersey. State counseling boards are
continually lobbied by CACREP to restrict
licensure to graduates of programs bearing
their accreditation.
3) A bill recently introduced in the U.S.
Senate (S. 562) would, if passed, extend
Medicare eligibility to licensed professional
counselors. Although there are no
restrictions by type/accreditation of degree
program in this bill, we are very concerned
by the precedent that has been set in the
regulations we have already described. If
a CACREP-only restriction were to be
inserted into Medicare regulations, we
believe that Medicaid and private insurers
would quickly follow suit, and in relatively
short order, the practices of all graduates
of programs not affiliated with CACREP
would be obliterated.
These challenges to the majority of
practicing professionals and counseling
students in the country need a vigorous
response. The rules need to be changed,
and further restrictions must be prevented.
What is happening now
Practicing professionals, for whom
CACREP may have seemed an
“academic” issue, may not be aware that
it serves only one slice of master’s- and
doctoral-level training programs. The
only programs eligible for CACREP
accreditation are those in “counseling”
or “counselor education.” CACREP
does not serve programs that grant
degrees with “psychology” in the name
(for example, a master’s in counseling
psychology) or whose core faculty
have degrees in psychology, identify
as psychologists or are otherwise
interdisciplinary, despite the fact that
these graduates are license holders and
license eligible in all 50 states.
Ironically, if Carl Rogers wished to hold
a core faculty position in a CACREP
program today, he would be prohibited
due to the requirement that only
counselor educators may occupy such
positions. Many of us received excellent
education and training from psychologists
and others whose training was in other
disciplines. We do not believe that
national certification and reimbursement
should be restricted to those who were
trained solely or primarily by counselor
educators, thus excluding qualified license
holders in every state.
We applaud and support the
educational standards that CACREP has
developed and the efforts to promote
these standards nationally. However, other
accrediting bodies with equally impressive
standards exist that accredit the programs
that CACREP does not. Many of our
members are graduates of or students in
these programs. A notable example is the
Council on Rehabilitation Education
(CORE).
All accrediting bodies share the
same mission — to train and graduate
counseling professionals of the highest
caliber. We can coexist peacefully and
strengthen each other by supporting
strong common core training and
diversity in faculty background as well as
programs’ specialty areas of expertise.
What needs to be done
1) We believe that CACREP-only
restrictions should be removed from
hiring and credentialing processes for
TRICARE and the VA and should not
be included in any future regulations (for
example, state licensure laws, Medicare
and private insurance regulations).
Restrictive supervision rules in the
TRICARE regulations must also be
removed. ACA has consistently requested
TRICARE policymakers to expand the
original, restrictive criteria, and we ask
the leadership to redouble efforts to
press for those changes. The TRICARE
rules are “interim final rules” and can
be changed. Because ACA’s requests of
regulators have not been effective to date,
we ask the ACA membership to join us in
lobbying our congressional delegations to
change the rules. Please send an email to
your representatives in Congress and urge
them to oppose the restrictive TRICARE
and VA regulations on your behalf.
2) Until CACREP-only language
and the restrictive supervision rule are
removed from TRICARE regulations,
the current interim rules for transition
to CMHC status in TRICARE
should remain open. Established and
emerging professionals who can meet
the supervision requirement should
be allowed to move into independent
CMHC status.
3) The requirement for CMHC
applicants to pass the NCMHCE
(the clinical counseling exam) should
commence in 2017, giving states that do
not currently use this exam a chance to
move to it in a reasonable way.
4) Please write (emails are more
effective than letters) to your senators
and congressional representatives and
ask them to support S. 562, which
would allow professional counselors to
participate in Medicare. We believe it
is very important that regulations are
written to allow all currently licensed
professional counselors to participate.
This is a matter of honoring the right
of states to determine the qualifications
for professional practice and to provide
much-needed services to citizens in
every state.
5) Regarding training standards, the
profession of mental health counseling
stands at a historic moment. Importantly,
delegates to the 20/20: A Vision for the
Future of Counseling initiative did not
reach agreement that graduation from
a CACREP-accredited mental health
counseling or clinical mental health
counseling program should be included
in model licensure language. We believe
that a more inclusive endorsement of
educational standards is needed and
should be part of all future federal and
state credentialing processes. Please
join with us in calling on the leadership
of ACA and its divisions to recognize
and affirm the value that CORE
has long brought to the training of
professional counselors and that other
accrediting bodies bring in providing
an alternate route to accreditation
for counseling programs in related
academic departments. Future initiatives
and regulations should recognize and
incorporate these accrediting bodies
alongside CACREP. In doing so, ACA
will affirm and continue its rich and
diverse intellectual history and serve the
best interests of all of its professional
counseling members.
u
Note: This article was submitted as a
joint effort of the boards of the Maryland
and Massachusetts chapters of AMHCA. u
Elaine Johnson is the graduate
program director at the University
of Baltimore. Larry Epp and
Courtenay Culp are president and
executive director, respectively, of
the Maryland chapter of AMHCA.
Midge Williams and David
McAllister are executive director
and associate executive director,
respectively, of the Massachusetts
chapter of AMHCA.
Letters to the editor:
[email protected]
Girls’ and Women’s Wellness:
Contemporary Counseling Issues and Interventions
Laura Hensley Choate
“This is an exciting resource for addressing girls’ and women’s issues from a strength-based, holistic
perspective that highlights resilience and coping. It will help women discover and actualize their
inherent potential for positive change.”
—Jane E. Myers, PhD
The University of North Carolina at Greensboro
In this empowering resource, mental health counselors, counselor educators, and school counselors will
find an abundance of practical strategies that can be used immediately in their daily practice. Each chapter
includes assessment and intervention strategies, client handouts, workshop outlines, self-exploration
activities, case studies with discussion questions, and recommended resources. Topics addressed include women’s development
and mental health, self-esteem, body image, relational aggression in girls, sexual assault and intimate partner violence, college
women’s experiences, life-work balance, spirituality, and the concerns of mid-life and older women. 2008 300 pages.
Order #72876
ISBN 978-1-55620-270-4
List Price: $55.95
ACA Member Price: $39.95
Please include $8.75 for shipping of the first book and $1.00 for each additional book.
AMERICAN COUNSELING ASSOCIATION • 800-422-2648 x222 • counseling.org
July 2013 | Counseling Today | 65
Division, Region & Branch News
ACCA preparing to
convene in the Big Easy
Submitted by Taffey Cunnien
[email protected]
Join us for the seventh annual
American College Counseling Association
Conference at the Roosevelt Hotel in
New Orleans from Sept. 25-28. We
have a diverse selection of programs
covering topics such as critical threat
assessment, leadership and supervision,
multicultural issues, community colleges,
outreach and group work. CE credits for
licensed professional counselors, social
workers and psychologists will be offered.
Preconference sessions on ethics, threat
assessment and our own advanced topics
in college counseling will be featured.
Please join us for an opportunity
to meet and network with colleagues
from across the country. For more
information, visit the conference website
at collegecounseling.org/conference or call us
toll free at 855.220.8760. Laissez les bons
temps rouler — let the good times roll!
NECA reflects on Day of Learning
Submitted by Kay Brawley
[email protected]
The National Employment Counseling
Association’s leadership team would like
to salute the success of NECA’s Day of
Learning at the American Counseling
Association 2013 Conference & Expo in
Cincinnati as well as our Distinguished
Service awardee, Sue Pressman, for her
continuing outstanding contributions to
the mission of NECA.
Some of the highlights of the Day of
Learning:
n A record number of participants
attended the Wellness at Work Institute
and the Presidential Reception, which
was cohosted with the Association
for Counselors and Educators in
Government.
n The success of NECA journal
editor Dale Furbish of the University of
Auckland, New Zealand, was recognized.
Members and colleagues are asked to
submit relevant research articles for
publication in NECA’s online Journal of
Employment Counseling. Send research
submissions to [email protected].
n The success of the NECA online
“Working Ahead, Moving Forward”
Global Career Development Facilitator
(GCDF) curriculum was applauded.
The online course is designed to improve
workforce professionals’ effectiveness
in the employment arena, regardless
of where one might work around the
world. The lead instructor for the next
GCDF course, beginning in September,
is employment counseling expert
Michael Lazarchick (mlazarchick.com).
For registration and more information
on this exciting online training, visit
employmentcounseling.org. u
Executive Director’s Message
continued from page 7
conference and exposition in
Honolulu (taking place March 2730, with preconference learning
institutes March 26-27). We have had
an amazing response to the call for
programs, so I am confident of the
high-quality programming we will be
featuring. And that is on top of the
networking and career development
opportunities that present themselves
in abundance when thousands of
counselors and counselor educators
gather under one roof.
During 2013-2014, our foray
into social media platforms such as
Facebook, Twitter, LinkedIn and
YouTube will continue to grow.
66 | ct.counseling.org | July 2013
This can no longer be classified as a
“wave of the future” or some “passing
fad.” We recognize just how much
information is shared and how
many discussions and idea exchanges
now take place through these sites,
so we are dedicating a number of
resources this year to enhance and
improve our involvement. But if you
aren’t as involved in social media,
don’t worry! We are still publishing
11 professional journals and 10 new
books (plus 12 monthly issues of
Counseling Today) that can be read
without an electronic device.
The need is great in our society
for those who work in professional
counseling. Your time is now. ACA
knows this, and I think that the public
does as well. ACA wants to be with
you every step of the way as you make
your mark in society for those facing
life’s challenges. I look forward to the
amazing year our association will have,
and I thank you for being part of our
community.
As always, I also look forward
to your comments, questions and
thoughts. Feel free to call me at
800.347.6647 ext. 231 or email me
at [email protected]. You can also
follow me on Twitter: @RichYep.
Be well. u
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THEORIES OF PSYCHOTHERAPY
The Association for Advanced Training in the Behavioral Sciences
Theories/Lead
Figures
Extended
Family Systems:
Main Idea
(Primary Concepts)
Extends family systems beyond
nuclear family – multigenerational.
• Virginia Satir
• Carl Whitaker
Structural
Family Therapy:
• Salvador Minuchin
Strategic
Family Therapy:
• Haley
• MRI
• Madanes
Narrative Therapy
(Post-Modern):
• Michael White
• David Epson
Current and extended family
therapy.
Long/short term.
• Murray Bowen
Experiential/
Communication:
Unit of Focus/
Length of
Treatment
Primary concept is self-esteem –
an innate drive either fostered
or not fostered as a result of the
communication and early experiences
a child receives from his/her parents.
Directive, change-oriented therapy,
concerned with symptoms in terms of
family system dynamics – assumption
that if you change the organization or
structure of the family, then the family’s
symptoms will be alleviated.
Family.
Long term/short term.
Nuclear family only.
Short/brief term.
Three main models: MRI, Haley
and Madanes, the Milan Model.
Relationships are characterized by
a struggle for power to see who will
define or redefine relationship.
Participants in the problem.
Focus on the stories of people’s lives
and is based on the idea that problems
are manufactured in social, cultural and
political contexts. Externalize problem.
Deconstruct story. Create new story.
Individuals, couples,
families and groups.
Short/brief term.
No time line. Depends
on clients and process of
retelling story.
Therapist’s
Role
Key Terms
Process of
Change/Insight
View of
Maladaptive
Behavior
Interventions Stages of
Treatment
Goals
Differentiation of self and fusion, emotional triangle,
nuclear family emotional system, emotional cutoff, sibling
position, family projection process, multigenerational
transmission process, genogram, family ego mass, society
emotional process.
De-triangulated
coaching. Supervisor.
Insight gained through
rationale/cognitive
processes leading to
differentiation and
understanding of family
of origin.
Behavioral disorders are
the result of a multigenerational transmission
process in which
progressively lower
levels of differentiation
are transmitted from one
generation to the next.
Beginning: Evaluation, trans-generational
exploration, identification of individualized
member.
Early/Middle: Teach differentiation,
individuation. genogram, therapy triangle,
relationship experiments, coaching and “I”
statements.
End: Reporting back. Closure.
Reduce the level
of anxiety and
alleviate symptoms.
Self-differentiation
within the context of
the family.
Self-esteem, self, primary triad, mind, soul, body triad,
maturation, seed model, threat and reward model,
placating, blaming, computing, distracting. leveling, rescue
games, coalition games, lethal games, growth games,
sculpting, family reconstruction, labeling assets.
Active facilitator of
communication and
growth. Promotes
spontaneity, creativity,
autonomy and ability
to play. Coaches
and teaches.
Family possesses all
resources needed for growth.
Looks for suppressed
feelings and emotions that
block growth & fulfillment.
Experiential awareness
important for growth.
Dysfunctional behaviors
are conceptualized as
resulting from failure to
fulfill one’s potential for
personal growth.
Beginning: Assessment: family history/key
relationship issues. Develop relationship and
establish goals.
Early/Middle: Treatment focuses on growth:
sculpting, family reconstruction, teaching and modeling
effective communication, use of metaphors, use of
drama, role play, therapist use of self, art therapy,
“I value you” statements, labeling.
End: Provide closure.
Raise selfesteem, improve
communication,
growth, identify
family roles and
how they promote
symptoms.
Family structure, subsystems, boundaries/degree of
permeability, diffuse boundaries and enmeshment, rigid
boundaries and disengagement, alignments, triangle,
power, coalition, joining, mimesis, tracking, enactment,
re-framing, unbalancing.
Active director of
therapy. Promoter
of change in
family structure.
Behavioral change is based
on action – action precedes
understanding.
Individual symptomology
or family dysfunction are
viewed as the result of an
inflexible family structure
that prohibits the family
from adapting.
Beginning: Acceptance of therapist by family.
Evaluate/assessment. accommodating, mimicking,
joining, mapping, challenging the symptom.
Early/Middle: Enactment, reframing, unbalancing,
redirection. Challenge the family structure.
End: Review progress made. Reinforce structure
and reorganization and provide tools for the future.
Setting up referrals or groups.
Primary
long-term goal is
to “restructure”
the family.
Circular questioning, neutrality, hypothesizing,
complementary, double bind concept, first order change,
metacommunication, paradoxical communications/
prescription, positive connotation, prescribing the system,
relabeling, second order change, symmetrical.
Active, take-charge
role. Power based.
Focus of therapy is
on alleviating current
symptoms through altering
a family’s transactions
and organization.
Insight considered
counterproductive as it
increases resistance.
Focus on how
communication is
used to increase one’s
control in a relationship.
Symptom is interpersonal
rather than intrapsychic.
Struggles for control
become pathological when
control issues produce
symptomatic behavior.
Beginning: Identify the problem. Plan a strategy
for change. Four Stages: Social stage, problem stage,
interaction stage, goal setting.
Early/Middle: Direct interventions/straight
directives/assignments/tasks. Paradoxical
directives to change dysfunctional behavior.
Circular questioning, neutrality, hypothesizing.
Address power struggles within family. Relabel
dysfunctional behavior.
End: Terminate. Presenting problem solved.
Change occurs
through actionoriented directives
and paradoxical
interventions.
Life stories, externalizing, who is in charge, reading between
the lines, reauthoring the whole story, reinforcing the new
story, de-constructing dominant cultural discourses.
Collaborative listener/
investigator reporter.
Strong interest in
client’s story.
Uses questions.
Change and insight occur
when a person’s story helps
him to regain his life from a
problem in the end. Process
of uncovering key values,
strengths and skills that lead to
an alternate direction in life.
There is no one objective
“truth” and there are
multiple interpretations
of any event. People are
not their problems and
can develop alternative
empowering stories once
they are separated from
their problems.
Beginning: Assessment. Externalizing – Client
tells their problem-saturated story. Therapist asks
questions/encourages clients to ask questions.
Early/Middle: Externalizing – the person is not
the problem. Mapping the influence – problem’s
effects rather than causes. Determine how problem
disrupts/dominates family? Discuss examples of
unique outcomes when clients could overcome
problem. Reauthoring the story. Reinforcing the
new story. Deconstruction.
End: Document and support new story. Make referrals.
Reauthoring the
whole story.
Association for Advanced Training
in the Behavioral Sciences
5126 Ralston Street, Ventura, CA 93003 | 800.472.1931 | www.aatbs.com | [email protected]
Association for Advanced Training
in the Behavioral Sciences
NCMHCE - EvaluatioN & assEsMENt
aCCulturatioN
Association for Advanced Training
in the Behavioral Sciences
NCE - HElpiNg RElATiONSHipS
RElABEliNg
(800) 472-1931
WWW.aatBs.CoM
Association for Advanced Training
in the Behavioral Sciences
Association for Advanced Training
in the when
Behavioral
Sciences
aCCulturatioN: A process of change that occurs
two cultures
come
(800) 472-1931
WWW.AATBS.COM
into contact. Occurs when an individual adopts the cultural traits (e.g., beliefs,
Association
for Advanced
Training
attitudes, values, language) of his or her new culture.
Most contemporary
models
of
in the
Behavioral
Sciencesthe
acculturation emphasize that it is an ongoing process,
involving
both adopting
traits of the mainstream society and giving up the traits of the indigenous culture.
These aspects of acculturation are not necessarily correlated, however; i.e., an
individual can adopt the traits of the dominant
culture withoutAssociated
abandoningwith
the structural
traits
RElABEliNg:
family therapy. Refers to deof his or her native culture. When counselingfining
a minority
group client,
the counselor terms instead of the individual ones
the symptom
in interpersonal
should determine the client’s degree of acculturation into the majority culture.
**
usually presented by the family. Relabeling usually involves changing a
label from a negative one to a positive one. Generally, it is a process of
or set of behaviors is understood. For ex(800) 472-1931
Association for Advanced Trainingchanging the way a symptom
in the Behavioral Sciences
WWW.aatBs.CoM
ample, an adolescent’s
behavior described by the parents as rebellious
and antagonistic may be relabeled as normative “growing up.”
Association for Advanced Training
in the Behavioral Sciences
Association for Advanced Training
in the Behavioral Sciences
Association for Advanced Training
in the Behavioral Sciences
(800) 472-1931
WWW.AATBS.COM
www.aatbs.com
Serving the Needs of Mental Health Professionals Since 1976
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