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Eating disorders and body image issues Also inside: n n n n 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.” u 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. n 11 percent (15 votes) viewed it in a negative light. n 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]. n 4 | ct.counseling.org | July 2013 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 You listen. You seek solutions. You make a difference. Rise to your calling. You’re “that friend” — the one everyone turns to when they have a problem. So why not fulfill your passion for helping others by earning your Master of Science in Counseling. Licensed mental health professionals teach all our classes in-person at 15 campus-based University of Phoenix locations. Our curriculum is rigorously aligned to national industry standards so you can prepare for state licensure. You’ll gain hands-on experience through an internship program and, with an average of 9 students per class, personal connections and perspectives to help you succeed. phoenix.edu/seeksolutions 866.291.8991 For more information about our on-time completion rates, the median loan debt incurred by students who complete a program and other important information, please visit our website at phoenix.edu/programs/gainful-employment.html The Master of Science in Clinical Mental Health Counseling (Arizona) and the Master of Science in Mental Health Counseling (Utah) programs are accredited by the Council for Accreditation of Counseling and Related Educational Programs (CACREP; cacrep.org). In order to practice as a counselor in any state, you must be licensed with a state license designation (i.e., LPC, LCPC, CCMH, MFT, etc.). License requirements and title vary by state. It is your responsibility to ascertain and meet licensure requirements in any state in which you desire to practice. University of Phoenix is accredited by the Higher Learning Commission and is a member of the North Central Association (ncahlc.org). The University’s Central Administration is located at 1625 W. Fountainhead Pkwy., Tempe, AZ 85282. © 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 Counselors-in-training, educators, and clinicians will benefit greatly from this in-depth and thought-provoking look at family violence, its effects, and treatment options. This book examines the major issues and current controversies in the field, provides background information on each type of family violence, and offers strategies for combating domestic abuse. In an informative discussion designed to enhance counselors’ ability to assess and treat each type of family violence, Dr. Lawson covers both well recognized forms of maltreatment, such as the abuse of women and children, and less understood issues, such as female-on-male intimacy violence, parent and elder abuse, same-sex violence, and dating violence and stalking. Case studies throughout the text illustrate clinical applications in action, and recommended readings are provided for further study. 2013 | 360 pgs | Order #78075 | ISBN 978-1-55620-317-6 List Price: $54.95 | ACA Member Price: $39.95 Order Online: counseling.org By Phone: 800-422-2648 x222 (M-F 8 a.m.–6 p.m.) Letters to the editor: [email protected] 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] Recovery from Grief Is Possible. Learn How to Help. Certification Training 2013 AUGUST SEPTEMBER 9–12 16–19 23–26 23–26 13–16 13–16 13–16 27–30 27–30 Wilmington, DE San Francisco, CA Omaha, NE Toronto, ON Portland, OR Cleveland, OH Jacksonville, FL Boston, MA Sherman Oaks, CA OCTOBER NOVEMBER 11–14 11–14 25–28 25–28 25–28 15–18 15–18 22–25 22–25 Denver, CO Memphis, TN San Diego, CA Indianapolis, IN Winnipeg, MB Des Moines, IA Princeton, NJ Sherman Oaks, CA Edmonton, AB 4-Day Training 30 Contact Hours Maximum 15 Participants Tuition $1995 (Early Registration Discount $200) For more information or to register Call 800-334-7606 www.griefrecoverymethod.com WHO ELSE WANTS TO SAY, “I PASSED”? Dr. Howard Rosenthal’s User-Friendly NCE/CPCE Exam Prep (www.howardrosenthal.com) All of Dr. Rosenthal’s materials are lively, easy-to-understand, and actually make exam prep enjoyable. The Special 15th Anniversary Edition, Encyclopedia of Counseling also known as the “purple book.” A publishers’ bestseller. Reads like a novel, imparts information like a post-graduate text. Loaded with memory devices. 654 pages. Includes 1050 tutorial questions and answers/final review. u 20 Audio CD Listen and Learn Vital Information and Review program turns a traffic jam or day at the beach into a world class learning experience. Totally different than the Encyclopedia. Upbeat presentations with alternative explanations covers all exam areas. Includes a test anxiety prevention CD, a last minute super review boot camp CD, and hundreds of practice questions. Informative and extremely entertaining. u Human Services Dictionary. A one-of-a-kind resource provides definitions purposely worded to help you tackle tough exam questions. u Membership in Dr. Rosenthal’s exclusive Inner Circle. Receive information and updates that might appear in future Rosenthal materials. Dr. Rosenthal’s best Valedictorian Mastery Tool Kit program is well under $200. Includes a risk reversal, better than money back pass guarantee. Perfect for the NCC, CPCE, oral and written boards and counseling comps. u For ACA member discount write Dr. Rosenthal personally at: [email protected]. Go to: www.howardrosenthal.com July 2013 | Counseling Today | 21 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] STUDY GUIDE for the NCE & CPCE and GUÍA DE ESTUDIO PARA NCE y CPCE Dr. Andrew Helwig’s very popular Study Guide for the NCE and CPCE (2011, 6th ed.) is also available in Spanish. This book has all eight CACREP content areas as well as information about the NCE and CPCE. Included are exam-taking tips, study strategies, 2 practice exams and the ACA Code of Ethics. This user-friendly Study Guide has 400 pages (430 Spanish). PDF FORMAT FOR DOWNLOAD TO YOUR COMPUTER NOW AVAILABLE For more information or to purchase the Spanish or English editions of the Study Guide ($79.95) or Workshop DVDs, visit: www.counselor-examprep.com. E-mail Dr. Helwig at: [email protected]. 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. 2013 | 512 pgs | Order #78076 | ISBN 978-1-55620-319-0 List Price: $54.95 | ACA Member Price: $39.95 Order Online: counseling.org By Phone: 800-422-2648 x222 (M-F 8am–6pm) 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 The International Institute of Souldrama ® Connie Miller, NCC, LPC, TEP, ACS • 800-821-9919 www.souldrama.com • [email protected] SOULDRAMA®, is a therapeutic technique which combines group and individual therapy, psychodrama and transpersonal therapy. The main objective of Souldrama is the psychological and spiritual development of the person. 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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] The Right Tool Can Make All the Difference Excelsior College offers online degree programs with the flexibility needed to accommodate individual goals and schedules, whether to meet your needs or the needs of your clients. A degree or certificate can provide the right tool at the right time. See how Excelsior can help build on individual success. www.excelsior.edu 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 TAkE EARN July 2013 Counseling Today, the CT Learning Test, Continuing Education Credit 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. It’s that simple! By reading Counseling Today every month, you can earn up to 12 CE credits each year. And you’ll be well informed. Start reading now! Article: Body language 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 q I certify that I have completed this test without receiving any help. Signature _____________________________________ Rate the following: Strongly agree Agree No opinion Disagree Strongly disagree 5 4 3 2 1 ______ I learned something I can apply in my current work ______ The information was well presented ______ Fulfillment of stated Learning Objectives was met ______ This offering met my expectations __________ Date Profession: ______ Alcoholism & Drug Abuse Counselor ______ Counselor ______ Counselor Educator ______ Psychologist ______ Social Worker ______ Student ______ Other Complete the test online at http://learning.counseling.org. You will be able to pay online and download your CE certificate immediately! Mail: Complete the test and mail (with payment made out to American Counseling Association) to: ACA Accounting Department/CT, American Counseling Association, 5999 Stevenson Ave., Alexandria, VA 22304. Your CE certificate will be emailed, unless noted otherwise, in 2–3 weeks. Questions? 800-347-6647, x306. Please print clearly Total amount enclosed or to be charged q $20.00 member q $30.00 nonmember Name: __________________________________________________________ ACA Member Number: _____________________________________________ Zip Code: ________________________________________________________ Phone: __________________________________________________________ Email:___________________________________________________________ q Check/money order (payable to ACA in U.S. funds) q VISA q MasterCard q American Express q Discover Card #: __________________________________ CVC Code: __ __ __ __ Exp. Date: ________________________ (AmEx, 4 digits above card number; VISA, MC, Dis., 3 digits by signature line) Cardholder’s Name: ___________________________________________________ Authorized Signature:__________________________________________________ July 2013 | Counseling Today | 45 New! Mastering the Art of Solution-Focused Counseling Second Edition Jeffrey T. Guterman “This 2nd edition is comparable to experiencing the latest model of a fine luxury car. While you may have thought improvements could not be made, the upgrade is noticeable, pleasing, professional, and surprising. Dr. Guterman gets his points across in interesting ways that make the trip through this book enlightening, delightful, and worthwhile.” —Samuel T. Gladding, PhD Wake Forest University The most current trends in solution-focused counseling are explored in the latest edition of this updated and expanded text. Dr. Guterman provides a comprehensive and straightforward discussion of solution-focused theory and describes how the model can be used throughout the therapeutic process. Clinical techniques and detailed case studies illustrate counseling with clients experiencing a range of problems, including depression, substance abuse, grief, morbid jealousy, and trichotillomania. New chapters and sections in this edition address anxiety, eating disorders, migraine headache, psychosis, spiritual and religious problems, self-injurious behavior, and suicide. Additional features include excerpts of dialogue from actual counseling sessions, sample forms and supplementary materials, and troubleshooting tips for getting unstuck in difficult cases. 2013 | 336 pgs | Order #78081 | ISBN 978-1-55620-332-9 List Price: $54.95 | ACA Member Price: $39.95 Order Online: counseling.org By Phone: 800-422-2648 x222 (M-F 8 a.m.–6 p.m.) 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 217-473 CalU SportCounseling_4.75x4.75 4c_Layout 1 1/25/11 9:56 AM Page 1 thought processes and schemas, SFBT Graduate Certificate in Sports Counseling 1 0 0 % O N L I N E Are you a practicing counselor, trainer or educator with a strong interest in working with athletes? The 100% online Graduate Certificate in Sports Counseling is designed for practicing counselors, counselors-in-training (post 48-credits), educators and/or other helping professionals who desire a specialty area of training with youth, adolescent, young adult, or adult athletes across a variety of settings. TO LEARN MORE e-mail [email protected], call 1-866-595-6348 or visit www.calu.edu/go. The Cal U Sports Counseling certificate program provides counselor training competencies in: • Foundations of sports counseling • Contextual dimensions of sports counseling, and • Knowledge and skills for the practice of sports counseling Note: The Graduate Certificate in Sports Counseling will not certify you as a professional counselor. However, courses may be utilized for additional credits toward licensure or for continuing education credits (CEU’s). California University of Pennsylvania School of Graduate Studies and Research Building Character. Building Careers. A proud member of the Pennsylvania State System of Higher Education. CALU GLOBAL ONLINE 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] Bulletin Board Coming events 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 COUNSELING EXAM PR E P AATBS Has EVERYTHING You Need to Pass Your Licensing Exam The First Time Our team of expert consultants are specially trained in effective preparation techniques and the demands of your exam. DR. JANIS FRANKEL 20 EXPERT CONSULTANT DAVE WADMAN DR. ALDEN HORI EXPERT CONSULTANT EXPERT INSTRUCTOR & CONSULTANT EXAM PREP * STUDY PACKAGES % OFF Use code: CTMFT Expires 07.31.2013 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 68 | ct.counseling.org | July 2013 • (800) 472-1931 *20% Off any exam preparation package valid toward new purchases ONLY Not valid on online mock-exam program extensions or continuing education. No retroactive discounts will be applied. You must enter or mention coupon code CTMFT prior to checkout to receive discount. Offer expires 07.31.13. 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