Tag Archives: Counseling

Personal Motivations for a Career in Counseling


I have a couple of different motivations for becoming a counselor.  The first one is, I know what it’s like to suffer from something you feel devastated about and to feel like you have no one on your side to help you.  I also know what it’s like to suffer from something you feel devastated about and to have a great support system.  It seems like one person should not have such a different experience when it comes to things that are happening to them or around them, but I think everyone goes through experiences where they have people who can relate, and then experiences where the people around them cannot relate at all.  When you have the support system, it is still never going to be easy, but to have someone you can talk to and tell your true feelings to, someone who won’t judge you, the healing is able to come faster.

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The second motivation I have is also my reward; I have people who often come to me so I will listen to them, and also for advice.  When they come to me and I see the light bulb come on, or they come back and say, “you know I tried that, and it’s working” or “I feel a lot better now”, it makes me feel like I’ve made a difference in that person’s world.  It makes me feel good to know that I’ve helped them in some way.  The smile or the look that someone gets when they realize it’s not too much, that they can pull through and they are not alone, that there is someone who understands.  It makes me very happy that I can be there for that person to help them come through whatever challenge they are facing at that time.

I have learned a few things about myself, one thing is that I have a talent and a purpose on this earth, and that is to help people get where they need to be.  I have also learned that I have more patience than I ever thought possible and that all the experiences I have been through in my life have been to help me understand what other people are experiencing.

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As I think about what my motivations are, I would say that I am so new to this field and even to the notion of becoming a counselor, that my motivations have not had a chance to change; I have only just found them.  I do feel that as I move along my journey my motivations will change and grow along with my goals.  If these things do not change and grow with you, then it seems you will go stale in the career and lose site of the reason you became a counselor in the first place.

A Look At The Counseling Side


It seems the Mental Health profession is still in its infancy and has been developing since 1979.  While mental health counseling was being practiced before 1979, it was at this time that members of the AMHCA, the American Mental Health Counselors Association, decided that Mental Health Counselors should be recognized as a core profession in the field.  This decision caused the members to select several steps that they felt would need to take place in order to make this happen.  The AMHCA spear headed this development piece by piece in order to ensure the continuation of each process.  They decided a membership association would be needed, they felt standards should be built on a national level so members who successfully passed would hold national certification, they had a vision that the education these members received would be accredited and training programs would be readily available.  These members also felt that licensure should be available in all 50 states and that the competencies in order to gain the licensure should be standard.

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These visions started to become reality in 1980 when certifications became available nationally and shortly after that the National Board for Certified Counselors which is now known as the Clinical Academy of NBCC or “The Academy”.  The certifications offered by this organization are completely voluntary and in 1999 around 2,000 counselors were Certified Clinical Mental Health Counselors or CCMHC’s, to date that number is over 1,000. We have gotten as far as to have license recognition in every state.  In 1999, only a handful of states had licensing or certification requirements, by 2004 licensure was recognized by 48 states, as well as in the District of Columbia, and Puerto Rico.  In 2007 Nevada recognized licensure and by January 2012 California counselors, both grandfathered and new will have their licenses recognized.  Getting the Mental Health Counselor recognized as an actual profession has taken over 30 years and is as of now an ongoing procedure.  The movement by the states to recognize licensure is a great one, but the titles of the professionals are varied by state and national certification by the NBCC is voluntary and does not provide the counselor a license to practice.

National licensure either in lieu of or required in addition to the state requirements would be a step in the right direction because the requirements would be more stringent and a counselor would be able to move states without having to find out and adhere to new state requirements.

In 1986 and 1987, comprehensive training standards were set for Clinical Mental Health Counselors in order to help them gain creditability and clinical skills.  A Clinical Counselor would need to have a minimum of 60 semester credit hours and a minimum of 1,000 clock hours of clinical supervision. There are literally hundreds of programs that will train counselors but most are not accredited by the Council for Accreditation of Counseling and Related Educational Programs, or, CACREP.  The standards set for a Clinical Counselor will not help them qualify for payment from a third-party payer such as private insurance or Medicare.  The standards for this privilege are much higher.  Third party payment wasn’t even a reality for the Mental Health Counselor until 1993 and was a strong concern until that time.  The standards were developed by the AMHCA and include having at least 3,000 hours of clinical experience, a minimum of 100 hours completed face-to-face supervision, a counselor must adhere to their appropriate association’s code of ethics, they have to achieve a passing score on the clinical exam, and submit an actual counseling session as well as have the appropriate licensing.  The certifications, education and licensing requirements have helped to make the Mental Health Counseling field strong but there are some concerns that we will need to address sooner or later.

In the world today, online counseling is gaining strength, which could be a threat to the traditional counselor.  If online counseling grows into something that is more acceptable or used more often than traditional services, counselors with state licensing would be forced to adjust and begin practicing this way, causing even more competition than before.  At this time in our lives, through this media anyone can be a counselor, the qualifications can range anywhere from a Dear Abby wannabe to a highly licensed and trained counselor.  The only proof generally offered is on the “About” page.  This type of counseling claims to be faster, but is it really?

Is sending an email about a problem you are having and then waiting for an answer completely comforting?  Of course, it is faster than having to research counselors and then wait for an appointment.  The draw would be that it is useful for people who are comfortable writing out their feelings and they would rather have the anonymity that comes with the internet.  If you have difficulty getting out of your house or have physical limitations or if you are uncomfortable with traditional counseling this would be a good solution.   Some concerns would be, first and foremost is the fact that a person’s non-verbal cues are not visible, this would include body language, facial expressions, hand gestures, and sitting positions, not to mention tone and inflection in a person’s voice cannot be heard.  How many times have you sent an email and then had to explain because the receiving party misinterpreted what you were trying to say?  This could be a big deal because this is at least half of how you learn about the person you are counseling.  Another concern would be the ability to understand what the counselor’s background is.  In order to be sure you are getting what is posted on a counselor’s website the minimal you would need to do would be to check with the Better Business Bureau, which is recommended no matter who you choose to help you.  You could also go as far as to check the counselor’s credentials with their respective schools or perform a background check which would cost even more money than what you are already spending on counseling.  In reality, most people will not check the credentials of the counselor, they will take what is given and run with it.

Lastly, since each state has their own regulations for licensing, if you get a counselor online who is not licensed in your state, they could be considered to be practicing illegally, so there is no recourse if you feel that you should be able to file a law suit for any reason.  The most logical solution to this would be that online counselors should be regulated and licensed as well, this will take a lot of legislation as well as time to make this happen, but it will be a reality in the years to come.

Salary seems to be another threat in the mental health field.  Once licensed, an entry-level salary is in the low $30,000 level.  This seems to be due to employment mainly in non-profit organizations where individuals are responsible for payment, which calls for a lower, more competitive fee.  It does seem like there is more movement into specialty areas of counseling which could be a solution to this problem.  Areas such as developmental disabilities, addiction disorders, chronic or fatal health conditions, and sex abuse victims, but at the same time this carries a threat of its own.  The risk of this would be that the counselor could end up in a niche that doesn’t suit him or her.  They may have a hard time getting into another specialty which could cause them to leave the field all together.  This is a double edged sword and it seems like to succeed in this field it would be a good idea while you are still in school to work or volunteer closely with counselors who are already in the profession you think would be a good fit.  This could enable a counselor starting out to begin at a higher level of salary.

It is very evident that the face of mental health is not a positive one. This is a threat not only for the counselors because it is considered taboo for a person to seek help, but also for the clients because they are easily labeled abnormal or crazy.  It seems that in order to try to move past the stigma we face as a mental health community, we need to focus more on awareness and sensitivity so that the people who aren’t currently undergoing any kind of treatment will understand why others feel the need to find ways to help themselves. We could accomplish this by speaking publicly in middle schools or high schools and definitely in colleges and participating more on a community level.  The more we can make people aware that the services we offer do not necessarily mean that our clients are insane, the better the communities around our clients will feel, and the better our clients will feel about what they are doing to help themselves.

With issues like these it is easy to tell the counseling field is still in the beginning stages of development where Mental Health Counselors are concerned.  Even though the mental health counseling field still has a long way to go it has made great strides in the recent past.

We have gained recognition in each state with licensure; we have come to a point where we can get paid through third-party payers, albeit with some pretty lengthy requirements, we have even entered the technological world with online counseling.  Will the salary ever catch up with the other advancements we have made?  Will public opinion ever move past the stereo type that because you have chosen to seek help, instead of go it alone, there must be something drastically wrong with you?  We will make these advancements as well, but only with hard work and persistence and it will definitely take longer than it should.

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References:

Mental Health Counseling: Past, Present, and Future. Journal of Counseling & Development; Current Issues Medicare Coverage of Licensed Professional Counselors. www.counseling.org;

Defining the mental health counseling profession: Embracing historical and contemporary perspectives at the interface of theory, practice, research, and professional exchange.  Journal of Mental Health Counseling;

What’s Next for the Profession of Mental Health Counseling?. Journal of Mental Health Counseling;

The American Mental Health Counselors Association: Reflection on 30 Historic Years. Journal of Counseling and Development : JCD

A Personal Narrative on Burnout: PTSD, Balancing Risks and Rewards in the Profession of Counseling


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I have resisted the temptation to share this up until now because it is a very personal article I wrote some time ago… this one goes out to Rey, my only subscriber.

Counseling is a risky and rewarding business.  While counseling invites mental health counselors to participate with their clients in the awesome process of human growth and healing, it also may threaten their well being through exposure to their clients’ trauma and its painful consequences.  (Meyer & Ponton, 2006)  The consequences frequently manifest themselves in adverse and maladaptive reactions to ongoing stress; peaking as a condition we call “burnout.”  The symbolism involved with the word burnout relates to the extinguished flame, which is the motivational force in the caring professions.  Burnout can be defined as a syndrome of emotional exhaustion, depersonalization, and reduced accomplishment which can occur among individuals who do “people work” of some kind.  (Garske, 2007)  Although exact figures are unknown, it is estimated that approximately 10-15% of practicing mental health professionals will succumb to burnout during the course of their careers.  (Clark, 2009)  Due to the emotional stresses involved with caring for others, and my own personal history of dealing with stress and trauma, there is good reason for us to explore strategies to thwart the effects of professional burnout.

I anticipate that I will be particularly prone to what has been described as “vicarious traumatization.”  Vicarious traumatization is conceptually realized through “the development of empathic relationships with traumatized clients,” ultimately leading some therapists to become traumatized themselves.  The impact of this traumatization is not limited to the therapeutic environment and may trickle into other aspects of the therapist’s life.  (Meyer & Ponton, 2006)  Although I have not yet assumed a role as a professional counselor, on occasion I am called upon to be a shoulder to cry on when traumatic events unfold.  On one such occasion, it would suffice to say that my shoulder was soaked.

I wouldn’t describe my relationship with my cousin Josh as “close.”  I saw him a couple times a year, usually around the holidays or for a week or so on summer vacation.  Josh was 6 years younger than me.  I was one of the people he “looked up to” when he was growing up; I guess you could say I was one of his role models.  Josh always wanted to be in law enforcement, mostly because he enjoyed the “action.”  He, too, had an intense desire to help people.  Josh joined the Army Reserves to leverage the GI Bill and pay for college.  Specifically, he joined the 339th Military Police Company based in Davenport, IA.  When he joined, it had been 30 years since that company was activated.  After a short deployment to Cuba, officials activated the 339th once again in December 2003 and the company deployed to Iraq in February 2004.  His mission included guarding people and enemy munitions located at a “forward operating base.”  When he came back, he was a wreck.  Haunted by visions of Iraqi people he had killed, and plagued by Post Traumatic Stress Disorder (PTSD), he took his own life in front of his mother (my aunt) on December 22, 2005.  Because the depth and detail of the situation is beyond the scope of this essay, I would point the interested reader to the award winning essay by Dennis Magee of The Des Moines Register, reproduced on the following site… http://joshua-omvig.memory-of.com/legacy.aspx

Although it is difficult to assess how work as a mental health professional will affect me, I can infer that vicarious traumatization might cause me to react much like I reacted to the second hand accounts of Josh’s suicide.  I did my best to assume as much of the burden as I was able; in hindsight, I probably took too much.  My natural inclination to withdraw took root weeks after the funeral, mostly as a reaction to shouldering the weight of my family and their grieving process.  I couldn’t sleep.  I couldn’t eat.  It’s difficult even writing about this now, nearly 5 years later.  As a counselor, I believe second hand accounts of a traumatic nature have the potential to reproduce that effect in me.  As a result, I have a sense of urgency creating a plan to deal with it.

Inherent in my plan to prevent burnout is continually access my level of competency and adjust the scope of my practice accordingly.  It is imperative for my success as a practitioner that I know my limits.  Due to my traumatic experience with PTSD veterans, I don’t anticipate working with this population in the immediate future.  I bestow all due respect to the women and men who have fought and died for our country, but my personal experience would prevent me from being fully effective as a therapist for our veterans.  Someday I hope to overcome this.

In addition to suffering vicarious symptoms of traumatic stress, therapists have to struggle with the same disruptions in relationships as their patients.  (Canfield, 2005)  I have experienced a wide range of difficult situations in my life, and I have little reason to believe that it will be “clear sailing” from here.  Although I have grieved for the loss of both friends and family, I have yet to endure the loss of any member of my immediate family.  I am the eldest son of a mother thrice divorced, but thus far I have managed to avoid the missteps that could cause the collapse of my own marriage.  Raising my daughter has not been without trials, but in her 8 years she has never been sick or injured without reasonable expectation of full recovery.  In the end, any or all of the above is possible (hopefully not likely).  It would suffice to say that my ability to maintain balance in my personal life will continue to have direct effects on my ability to provide effective counsel.

To that end, I endeavor to continually invest in myself and my personal well being through my family life.  My personal life begins and ends with my family, and to what degree it is possible, I spend as much quality time as I can with them.  It’s as simple as taking the time to read to my daughter every night, or surprising my wife with flowers for no apparent reason.  My father once told me that I should “cherish every day like it was my last.”  That realization, that process, is at the core of my personal burnout plan.

Third and finally, I believe one area of significant vulnerability for me is my excessively preoccupation being successful.  Work tends to play a central role in people’s physical and psychological well-being, I am no exception. “Not only does it provide income and other tangible resources, but also it may be a source of status, social support, life satisfaction, and self-identity.”  (Garske, 2007, expression Nature)  No one likes to fail.  Too often, being anything less than the best is failure in my eyes.  Competitiveness is in my nature; the chase causes me a great deal of stress.

An integral part of my burnout plan involves individual therapy.  My persistent and unrelenting determination occasionally causes me a great deal of stress.  In the end, like our clients, it helps to talk about it.  Therapists cannot take clients any further than they have taken themselves; therefore ongoing self-exploration is important.  (Corey, Schneider-Corey, & Callanan, 2007, p. 73)  I am an advocate of counseling for counselors.  Without, I wouldn’t be writing this paper if not for my successes in individual therapy; I’d probably be burned out.

In closing, I believe we all struggle to balance the risks and rewards of life.  For every day I have spent grieving over a fallen solider, I should spend a reciprocal day defining my limits and reducing potential risks of transference.  For every hour I have spent mulling over the tragedies of yesterday and tomorrow, I should spend a reciprocal hour appreciating today.  For every minute I spend rushing to the destination, I should spend a reciprocal minute examining the road.  In the end, it’s all about achieving balance.  Balancing the risks and rewards could mean the difference between success and failure, not just for me as a clinician, but for the clients I endeavor to help.

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References

Canfield, J. (2005). Secondary traumatization, burnout, and vicarious traumatization: A review of the literature as it relates to therapists who treat trauma. Smith College Studies in Social Work, 75(2), 81-102. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1061959531&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Clark, P. (2009, Apr). Resiliency in the practicing marriage and family therapist. Journal of Marital and Family Therapy, 35(2), 231-248. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1680596541&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Corey, G., Schneider-Corey, M., & Callanan, P. (2007). Issues and ethics in the helping professions (8th  ed.). Belmont, CA: Brooks/Cole.

Garske, G. G. (2007, Winter). Managing occupational stress: A challenge for rehabilitation counselors. Journal of Applied Rehabilitation Counseling, 38(4), 34-42. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1418538171&sid=3&Fmt=4&clientId=4683&RQT=309&VName=PQD

Meyer, D., & Ponton, R. (2006, Jul). The healthy tree: A metaphorical perspective of counselor well-being. Journal of Mental Health Counseling, 28(3), 189-202. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1086418421&sid=3&Fmt=4&clientId=4683&RQT=309&VName=PQD

Skovholt, T. M., & Ronnestad, M. H. (2003, Fall). Struggles of the novice counselor and therapist. Journal of Career Development, 30(1), 45. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=420397201&sid=1&Fmt=2&clientId=4683&RQT=309&VName=PQD

Feeding Disorders of Infancy and Early Childhood


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Herein lies a brief overview of the epidemiology, theoretical models, assessment techniques, and intervention methods as it relates to Pica (307.52), Rumination Disorder (307.53), and Feeding Disorder of Infancy and Early Childhood (307.59).

Pica is the persistent ingestion of nonnutritive substances including paint, plaster, hair, cloths, toys, feces, sand, and bugs.  (Netherton, Holmes, & Walker, 1999, p. 139)  The term pica comes from the Latin for “magpie,” a bird known for voraciously eating food and nonfood items alike.  (Stiegler, 2005, expression Abstract)  Exploration of objects by mouthing and tasting is part of normal, healthy development and is not considered pathological pica behavior. Pica is suspected only when (a) nonfood items are consumed repeatedly over the course of a month or longer, despite efforts to curtail the behavior; (b) the behavior is considered inappropriate for the individual’s developmental age (i.e., beyond the 18-month level); (c) it is not a cultural practice; and (d) the behavior is a symptom of another mental disorder and is of sufficient concern to warrant medical attention.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 103)  On the whole, what surprised me most, what the distinct lack of aversion to food.  I would have expected that kids subject to pica would abstain or otherwise have trouble eating “real food,” but that is not the case with pica.  I was also surprised and that behavioral interventions included punishment, which is a first in my research.  It’s not that I particularly enjoy disciplining kids, but I do marvel at the novelty of having a psychologist tell me it’s perfectly acceptable… here I thought it was a lost art?

Rumination is the practice of voluntarily bringing previously ingested food back into the oral cavity and then either ejecting it or re-chewing and swallowing.  (Netherton et al., 1999, p. 140)  My first reaction was “gross!”  Evidently I wasn’t the only one since “social interactions with the infant or individual with mental retardation can be adversely affected by the unpleasant nature of this behavior.”  (Netherton et al., 1999, p. 141)  I was suitably surprised that researchers found willing parents that would subject their children to electric shock therapy.  It seems a bit extreme, but the cases were described as “life-threatening” and it proved to work.  (Netherton et al., 1999, p. 141)

The list of MR comorbid pathologies with is growing; we can add feeding disorders to the list of possible comorbid pathologies among the developmentally disabled population.  (Netherton et al., 1999, p. 143)  Aside from the specific exclusions, it would appear that MR is comorbid with just about everything?

Finally, the most intriguing aspect for me the research performed that implicated paternal influences in feeding disorders.  This is the first disorder I have experienced that would suggest “global family functioning and parental interactions may have both direct and indirect effects” on the pathological development of a disorder.  Drotar and Sturm (1987) suggested that (1) conflictual relationships between the parents, (2) inconsistent paternal support for the mother, (3) paternal psychopathology (e.g., substance abuse, domestic violence), (4) poor paternal nutritional standards, and (5) the fathers infantilization of the child may all act to interfere with the maternal-child feeding dyad.  (Netherton et al., 1999, p. 145)  As a guy, I thought it was refreshing that psychology professionals give us some credit for the development of the kids, even if it is in the negative context.  If we have potential to do harm, I hope later in the text they acknowledge our ability to nurture?

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Stiegler, L. N. (2005, Spring). Understanding pica behavior: A review for clinical and education professionals. Focus on Autism and Other Developmental Disabilities, 20(1), 27-39. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=809692351&sid=1&Fmt=4&clientId=4683&RQT=309&VName=PQD

Roles of the Counselor with Learning Disabled Clients and Families


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Is there a counseling or therapeutic role in the context of these disorders, or is the role of the counselor primarily a social/educational one?  It’s a complex question regarding a complex disorder; there are no simple solutions.  Within the context of learning disabilities (LD) and mental retardation, there are a number of different roles we, as human services or mental health professionals, can fill in the multidisciplinary model of treatment for clients with LD.   Our expertise is needed not only by the clients themselves, but also by the families who endeavor to provide support for special needs individuals.  Finally, we should not discount our role in supporting other professionals, as we can have an impact, even if indirect, by allowing them to continue to function effectively in those sometimes challenging roles.

Direct treatments of clients with LD are most often focused on adaptation skills “since problems in adaptation are more likely to improve with remedial efforts than is the cognitive IQ, which tends to remain a more stable attribute.”  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 42)  Traditional interventions for children with learning and coordination disorders include: (1) general educational management of learning-disabled children eligible for special education services in the public schools; (2) specific methods of instruction; (3) cognitive-behavioral techniques to teach efficient problem strategies and to improve attitudinal/motivational problems, and (4) mental health approaches with children who have co-occurring social-emotional disorders.  (Netherton, Holmes, & Walker, 1999, p. 40)

A contemporary program that extends the boundaries of more traditional interventions is the “treatment mall.”  The programming (in the treatment mall model) is the result of a collaborative process involving the patient, his or her treatment team, a program design team (which has participant representation), and group facilitators from the many disciplines that practice in the treatment mall.  The emphasis of psychosocial rehabilitation programming is improving functional level, increasing capacity for recovery, and instilling hope.  Psychosocial rehabilitation treatment malls use a multidisciplinary team approach.  Nurses, psychologists, rehabilitation therapists, social workers, nutritionists, physical therapists, physicians, community college educators, and community support providers work together to teach patients with serious mental illness or mental retardation and developmental disabilities the skills and adaptive behaviors needed to live successfully in a community setting following discharge from the hospital.  (Ballard, 2008, expression Program Description)  The sidebar of the Ballard article specifically recognizes psychology staff as contributing to courses designed for short stay participants, including courses titled Legal Issues/Focus, Understanding Your Illness, Competency Restoration, Building Your Brainpower, and Building the Life You Want.  (Ballard, 2008, expression Sidebar)

Our contributions to the learning disabled community as mental health professionals are not confined to treatment malls.  High levels of frustration, with associated performance anxiety and depression, are not uncommon in LD children.  (Netherton, Holmes, & Walker, 1999, p. 45)  Accurate diagnosis provides a clear direction for interventions.  (Costello & Bouras, 2006, expression abstract)  Although substantially increased in recent years, research evidence about the prevalence of mental health problems in individuals with intellectual disabilities and the risk factors for developing specific psychiatric disorders is limited and often conflicting.  Most estimates of the prevalence of psychiatric illness in people with intellectual disabilities range from 10-39%.  (Costello & Bouras, 2006, expression Prevalence)  This suggests that our role isn’t simply confined to teaching problem solving techniques and life skills, but more importantly, addressing the underlying psychological issues that impact the learning disabled community as a whole.  Large numbers of individuals with intellectual disabilities living in the community exhibit psychiatric or behavioral problems arising from mental health problems.  Together the joint contributions of mental illness and intellectual disabilities indicate a group of individuals whose needs are considerable, and whose quality of life will be seriously impaired if the illness is not effectively identified and treated.  (Costello & Bouras, 2006, expression Implications)

So, to answer the question… Is there a counseling or therapeutic role in the context of these disorders, or is the role of the counselor primarily a social/educational one?  Yes, all of the above.  As we continue to define our roles, inevitably we will continue to develop new models of treatment and rehabilitation for our LD clients.  I contend that mental health professionals play a critical role at every point of entry, and should continue to play a significant role into the foreseeable future.

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Ballard, F. A. (2008, Feb). Benefits of psychosocial rehabilitation programming in a treatment mall. Journal of Psychosocial Nursing & Mental Health Services, 46(2), 26-33. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1422243211&sid=6&Fmt=3&clientId=4683&RQT=309&VName=PQD

Costello, H., & Bouras, N. (2006). Assessment of mental health problems in people with intellectual disabilities. The Israel Journal of Psychiatry and Related Sciences, 43(4), 241-252. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1254155791&sid=6&Fmt=3&clientId=4683&RQT=309&VName=PQD

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

State of the Union in Mental Health


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The first ever surgeon general’s report on the “state of the union” in mental health was issued in 1999.  David Satcher, (now former) Surgeon General of the United States, emphasized the importance of adopting a public health perspective, accepting that mental disorders are disabling, and seeing both mental health and mental illness as points on a continuum.  (U.S. Department of Health and Human Services, 1999)  He highlighted overarching themes of reducing and eliminating the stigma associated with mental illness, the importance of a solid research base to evaluate the practicality and effectiveness of new approaches, and overall accountability to the individuals for whom and intervention is intended.  (Satcher, 2000)  Satcher’s submission represents a blueprint for change.  It’s been 10 years since this comprehensive report. This essay will attempt to access the following question: “How have we done?”

The foundation of Satcher’s public health perspective was rooted in the concept of preventive interventions.  Since 1999 we have made significant progress in developing family-focused preventative interventions (Redmond, Spoth, Shin, & Lepper, 1999) including mother and mother-child programs for children of divorce (Wolchik et al., 2000).  We have adopted an early intervention strategy and attempted to focus our preventative efforts on the individuals who have the most to gain/lose, children.  Preventative efforts focused on coping with anger and stress, family bereavement, bullying, early conduct disorder, social relations, stress inoculation, and suicide prevention are yielding significant results among school-aged children.  (Greenberg, Domitrovich, & Bumbarger, 2001; Shaw, Dishion, Supplee, Gardner, & Arnds, 2006; Weissberg, Kumpfer, & Seligman, 2003)  The underlying theory of many, if not most, of these research efforts is that “prevention programs enhance children’s socio-emotional competence and prevent the emergence of behavior problems.”  (Webster-Stratton, 2003)

Although research suggests that there are correlates of life satisfaction in those with disabling conditions, much of the work has been focused on physical disabilities as opposed to mental illness.  (Mehnert, Krauss, Nadler, & Boyd, 1990; Schröder et al., 2007)  More work remains to be done regarding overall public awareness of exactly how debilitating mental illness can be.  This is particularly true in the cases where individuals whom are heavily medicated may be more disabled by their medication than by the mental illness itself.  (Waldman, 1999)

If we consider seeing mental health and mental illness as points on a continuum a goal, then we should consider ourselves closer to that goal then we were 10 years ago.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000)  Differential diagnosis is more prominent in the DSM-IV-TR than it was in any previous revision of the DSM, and we have every expectation that we will continue to see movement towards continuum based differential diagnosis in the upcoming DSM-V.    As a profession, we can expect that the differentiation between normal psychological functioning and pathological functioning will continue to be defined, or redefined.  (Widiger & Clark, 2000)  We can expect that diagnostic categories be removed, added, merged, linked, or otherwise cross referenced to reflect the “points on a continuum” perspective.  If I could predict the specific changes we should expect I wouldn’t be here, but I can be fairly certain that we should expect change in general.

Reducing and eliminating the stigma associated with mental illness is a tall order that is constantly in the process of fulfillment.  Despite persistent efforts, anti-stigma campaigns have not yet resulted in the desired changes in public attitudes and perceptions.  (McNulty, 2004)  “Many people who would benefit from mental health services opt not to pursue them or fail to fully participate once they have begun.  One of the reasons for this disconnect is stigma; namely, to avoid the label of mental illness and the harm it brings, people decide not to seek or fully participate in care.”  (Corrigan, 2004, p. 614)  The availability of accurate information, persistent social marketing, and direct contact with the mentally ill can effectively combat the negative stereotypes associated with individuals who suffer from mental illness.  (Kirkwood & Hudnall, 2006)  Nonetheless, there is much work to be done… it is certainly a work in progress.  Furthermore, the DSM has made an effort to reduce stigma by changing verbiage.  For example, people who suffer from alcoholism are no longer referred to as “alcoholics” in an effort to focus on the disease, not the deficiency of the individual.

Nowhere have we made more progress than in the arena of developing a solid research base.  Never before in human history have individual clinicians had access to the depth, breadth, and quality of research that we have today.  This is due, in large part, to technology and the advent of reference-able online material.  Scholars are no longer required to scour books at the library in search of support… we simply find a keyword and plug it into resources like Google, ProQuest, PsycARTICLES, WilsonWeb, ERIC or MEDLINE.  The efficient dissemination of information is critical to our success as a mental health community because it prevents duplicate research efforts.  It also provides instant access to research that can justify both diagnosis and treatment modalities.

We have also made significant progress in the form of accountability.  Federal and state regulatory authorities are constantly reviewing, revising, and reinforcing quality control practices with regard to education and credentialing of mental health professionals.  (Nelson, 2007)  Despite the fact that outcome evaluation programs are becoming more common with regard to child welfare services, they are still lacking in the field of mental health as a whole.  (Wall et al., 2005)  Informed consent is now mandatory in most states, although there is a definitive lack of consistency in terms of what that informed consent document should contain, or how clearly it should be worded.  (Walfish & Ducey, 2007)

There’s more work to be done, so the progress doesn’t stop here.  Our profession is currently being assaulted by rigorous cost control efforts in the form of managed care.  Increasingly, insurance companies are making the decision what is best for clients, not their caregivers… or, if the caregivers do weigh in on the decision, it is with the constraints of a limited number of sessions or available treatments.  Although we have made considerable progress on a number of fronts, including information dissemination, accountability efforts, reducing stigmas, and prevention… all of these avenues of progress will need continued emphasis into the 22nd century in order to have a lasting effect on the profession as a whole.

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Corrigan, P. (2004, Oct). How stigma interferes with mental health care. American Psychologist, 59(7), 614-625. doi: 10.1037/0003-066X.59.7.614

Greenberg, M. T., Domitrovich, C., & Bumbarger, B. (2001, March). The prevention of mental disorders in school-aged children: Current state of the field. Prevention & Treatment, 4(1), [np]. doi: 10.1037/1522-3736.4.1.41a

Kirkwood, A. D., & Hudnall, S. B. (2006, Oct). A social marketing approach to challenging stigma. Professional Psychology, 37(5), 472-476. doi: 10.1037/0735-7028.37.5.472

McNulty, J. P. (2004). mmentary: Mental illness, society, stigma, and research. NIMH, Schizophrenia Bulletin, 30(3), 573-575. Retrieved from http://ft.csa.com.ezproxy.bellevue.edu/ids70/resolver.php?sessid=ruib4jnm5uafkc6aefn5lthuo0&server=csaweb106v.csa.com&check=ab5542fe87c5d81a32140a205b771a50&db=psycarticles-set-c&key=SZB/30/szb_30_3_573&mode=pdf

Mehnert, T., Krauss, H. H., Nadler, R., & Boyd, M. (1990). Correlates of life satisfaction in those with disabling conditions. Rehabilitation Psychology, 35(1), 3-17. doi: 10.1037/h0079046

Nelson, P. D. (2007, Feb). Striving for competence in the assessment of competence: Psychology’s professional education and credentialing journey of public accountability. Training and Education in Professional Psychology, 1(1), 3-12. doi: 10.1037/1931-3918.1.1.3

Redmond, C., Spoth, R., Shin, C., & Lepper, H. S. (1999, Dec). Modeling long-term parent outcomes of two universal family-focused preventive interventions: One-year follow-up results. Journal of Consulting and Clinical Psychology, 67(6), 975-984. doi: 10.1037/0022-006X.67.6.975

Satcher, D. (2000, Feb). Mental health: A report of the Surgeon General–Executive summary. Professional Psychology, 31(1), 5-13. doi: 10.1037/0735-7028.31.1.5

Schröder, C., Johnston, M., Morrison, V., Teunissen, L., Notermans, N., & Van Meeteren, N. (2007, Aug). Health condition, impairment, activity limitations: Relationships with emotions and control cognitions in people with disabling conditions. Rehabilitation Psychology, 52(3), 280-289. doi: 10.1037/0090-5550.52.3.280

Shaw, D. S., Dishion, T. J., Supplee, L., Gardner, F., & Arnds, K. (2006, Feb). Randomized trial of a family-centered approach to the prevention of early conduct problems: 2-year effects of the family check-up in early childhood. Journal of Consulting and Clinical Psychology, 74(1), 1-9. doi: 10.1037/0022-006X.74.1.1

U.S. Department of Health and Human Services. (1999). Mental health: A report of the surgeon general. Retrieved from http://www.surgeongeneral.gov/library/mentalhealth/home.html

Waldman, E. (1999, Dec). Substituting needs for rights in mediation: Therapeutic or disabling?. Psychology, Public Policy, and Law, 5(4), 1103-1122. doi: 10.1037/1076-8971.5.4.1103

Walfish, S., & Ducey, B. B. (2007, April). Readability level of Health Insurance Portability and Accountability Act notices of privacy practices used by psychologists in clinical practice. Professional Psychology, 38(2), 203-207. doi: 10.1037/0735-7028.38.2.203

Wall, J. R., Busch, M., Koch, S. M., Alexander, G., Minnich, H., & Jackson-Walker, S. (2005). Accountability in child welfare services: Developing a statewide outcome evaluation program. Psychological Services, 2(1), 39-53. doi: 10.1037/1541-1559.2.1.39

Webster-Stratton, C. (2003). Aggression in young children services proven to be effective in reducing aggression. Retrieved August 8, 2010, from http://www.child-encyclopedia.com/en-ca/child-aggression/according-to-experts/webster-stratton.html

Weissberg, R. P., Kumpfer, K. L., & Seligman, M. E. (2003, June/July). Prevention that works for children and youth: An introduction. American Psychologist, 58(6-7), 425-432. doi: 10.1037/0003-066X.58.6-7.425

Widiger, T. A., & Clark, L. (2000, Nov). Toward DSM—V and the classification of psychopathology. Psychological Bulletin, 126(6), 946-963. doi: 10.1037/0033-2909.126.6.946

Wolchik, S. A., West, S. G., Sandler, I. N., Twin, J., Coatsworth, D., Lengua, L., … Griffin, W. A. (2000, Oct). An experimental evaluation of theory-based mother and mother–child programs for children of divorce. Journal of Consulting and Clinical Psychology, 68(5), 843-856. doi: 10.1037/0022-006X.68.5.84

Evidence Based Practice (EBP) and Managed Care


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Evidence-based Practice (EBP) is based on three pillars: “looking for the best available research, relying on clinical expertise, and taking into consideration the client’s characteristics and preferences.”  (Corey, Schneider-Corey, & Callanan, 2007, p. 446)  The suggestion is that we, as practitioners, should strive to provide minimum amount of treatment that gives maximum benefit in the least amount of time… as supported by the managed health care system that has been “the driving force in promoting empirically supported treatments (EST).”  (Corey et al., 2007, p. 443)

Where the EST system falls short is the fact that there can be a wide variation in presentations within one specific categorical diagnosis.  I agree with the premise that “this approach is mechanistic and does not take into full consideration the relational dimensions of the psychotherapy process.”  (Corey et al., 2007, p. 443)  What if, for example, the recommended treatment modality is obviously not sufficient to effectively treat an individual client?  What if, at the close of the 5th or the 6th session, the client has made little or no progress as a result of the ESTs?  Despite the focus on “best available research,” there is no single identified treatment method that works for everyone.  When EST fails, is the system flexible enough to recognize its shortcomings?

The concept of EBP and EST are in fact theory laden, but I question whether ever practicing clinician subscribes to that theory.  It is generally acknowledged that a practicing clinician should anchor his or her methodology to a theory… but if that theory differs from the 3rd party payer, I suspect that the clinician would be better off working outside of the managed care system.  My question is this… is that even possible today?  Can you effectively run a private practice and not accept EAP or managed care as a 3rd party payer?  If we choose not to accept those types of clients, isn’t that discrimination in its own right?

I am in support of the general underlying premise of EBP and EST, lowering costs and raising the quality of care should be something we should all aspire to.  However, I fail to see how force feeding a theoretical system on practitioners is in any way conducive to raising the quality of care… it would appear that it is 100% focused on lowering costs.  After all, lower costs are quantifiable (measured in $), and the relative quality of care is subjective.

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