Motivations for Becoming a Counselor

Motivations for Becoming a Counselor

Eloise is a high school counselor who is presently experiencing a traumatic personal crisis. Her only son was killed in a drive-by shooting. Many of the students in her school are gang members. She becomes aware of increasing countertransference and at times has an impulse to lash out at some of her student counselees. Eloise is frequently overcome by grief and is aware that her effectiveness as a counselor is severely impaired. Eloise confides in her colleague, Peter, all the ways she is being negatively affected by the death of her son. Peter is supportive and recommends that she seeks professional counseling. She does not follow through on this recommendation. Peter is made aware that some of her counselees are being negatively affected by her impairment.

After reading the case study for Unit 2, what ethical responsibility does Peter have in this case? How would you deal with Eloise?

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Ch. 2 The Counselor as a Person and as a Professional

Ask yourself these two questions: “What motivates me to become a counselor?” and “What are my rewards for counseling others?” There are many answers to these questions. You might experience a sense of satisfaction from being with people who are struggling to achieve self-understanding and who are willing to experience pain as they seek a healthier lifestyle. Addiction counselors who are themselves in recovery, for example, may appreciate being part of the process of change for others with substance abuse problems. Indeed, many counselors have been motivated to enter the field because of their own struggles in some aspect of living. It is crucial to be aware of your motivations and to recognize that your way of coping with life’s challenges may not be appropriate for your clients. In many ways therapeutic encounters serve as mirrors in which therapists can see their own lives reflected. As a result, therapy can become a catalyst for change in the therapist as well as in the client.

Of course, therapists do have their own personal needs, but these needs can- not assume priority or get in the way of a client’s growth. Therapists need to be aware of the possibility of working primarily to be appreciated by others instead of working toward the best interests of their clients. Therapeutic progress can be blocked if therapists use their clients, even unconsciously, to fulfill their own needs. Although therapists may meet some of their needs through their work, this should be a by-product rather than a primary aim.

Out of an exaggerated need to nurture others or to feel powerful, professional helpers may come to believe that they know how others ought to live. Some coun- selors may be tempted to use their value system as a template for their clients, but giving advice and directing another’s life encourages dependence and promotes a tendency for clients to look to others instead of to themselves for solutions. Part of the therapist’s job is to empower clients so they can function independently and discover their own unique solutions. Therapists who need to feel powerful or important may begin to think that they are indispensable to their clients or, worse still, try to make themselves so.

The goals of therapy also suffer when therapists with a strong need for approval focus on trying to win the acceptance, admiration, and even awe of their clients. When we are unaware of our needs and personal dynamics, we are likely to satisfy our own unmet needs or perhaps direct clients away from exploring con- flicts that we ourselves fear. Some clients may feel a need to please their therapist, and they are easily drawn into taking care of their therapist’s psychological needs. Relying too heavily on personal self-disclosure when working with clients moves the focus away from our clients and puts the spotlight on the therapist.

Some therapists feel ill at ease if their clients fail to make immediate progress; consequently, they may push their clients to make premature decisions or may make decisions for them. As a way of understanding your needs and their possible influence on your work, ask yourself these questions:

How will I know when I’m working for my own benefit at the expense of my client’s benefit?
If I have personal experience with a problem a client is having, how can I work to be objective enough to relate to this person professionally and ethically?

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How much do I depend on being appreciated by others in my own life? Do I depend primarily on sources outside of myself to confirm my worth?
Am I getting my needs for nurturance, recognition, and support met from those who are significant in my life?
Do I feel inadequate when clients don’t make progress? If so, how could my atti- tude and feelings of inadequacy adversely affect my work with these clients?
Do I have healthy boundaries in place and set limits for myself both person- ally and professionally?

Personal Problems and Conflicts

Mental health professionals can and should be aware of their unresolved problems and conflicts. Personal therapy may reduce the intensity connected with these problems, yet it is not realistic to believe that such problems are ever fully resolved. Clearly, then, we are not implying that therapists should have resolved all their per- sonal difficulties before they begin to counsel others. Indeed, such a requirement would eliminate most of us from the field. In fact, a counselor who rarely struggles may have real difficulty relating to a client who feels desperate or is caught in a hopeless conflict. The critical point is not whether you happen to be struggling with personal problems but how you are dealing with problems you face.

Reflect on the following questions: Do you recognize and try to deal with your problems, or do you invest a lot of energy in denying that you have problems? Do you find yourself blaming others for your problems? Are you willing to con- sult with a therapist, or do you tell yourself that you can handle it, even when it becomes obvious that you are not doing so?

When you are in denial of your own problems, you will most likely be unable to pay attention to the concerns of your clients, especially if their problem areas are similar to yours. Suppose a client is trying to deal with feelings of hopelessness and despair. How can you explore these feelings if in your own life you are deny- ing them? Or consider a client who wants to explore her feelings about her sexual orientation. Can you facilitate this exploration if you feel uncomfortable talking about sexual identity issues and do not want to deal with your discomfort? Some- times it can be difficult to identify strengths and weaknesses. We encourage you to ask colleagues, peers, and your personal counselor for honest feedback as to how they perceive you and what they see as your strengths and areas needing further work for you as a person and a professional. Asking for this type of feedback requires courage, yet doing so can be an illuminating experience and well worth the effort. When engaged in this discussion, willingly suspend any tendency to be defensive. Reflect on the information shared and create a plan to learn from it, integrate it, make changes, and move forward.

You will have difficulty helping a client in an area that you are reluctant to look at in your own life. It is important to recognize the topics that make you uncomfortable, not just with clients, but in your personal life as well. Knowing that your discomfort will most probably impede your work with a client can sup- ply the motivation for you to change and to realize that you also have an ethical responsibility to be present with your clients. One of the gifts of being a counselor is that it is a career choice that can lead us to becoming better versions of ourselves.

How much do I depend on being appreciated by others in my own life? Do I depend primarily on sources outside of myself to confirm my worth?
Am I getting my needs for nurturance, recognition, and support met from those who are significant in my life?
Do I feel inadequate when clients don’t make progress? If so, how could my atti- tude and feelings of inadequacy adversely affect my work with these clients?
Do I have healthy boundaries in place and set limits for myself both person- ally and professionally?

Personal Problems and Conflicts

Personal Therapy for Counselors

Throughout this chapter we stress the importance of counselors’ self-awareness. A closely related issue is whether those who wish to become counselors should experience their own personal psychotherapy, and also whether continuing or peri- odic personal therapy is valuable for practicing professionals. We strongly support the value of personal therapy for counselors in training because it provides a win- dow into what counseling might be like for clients. Wise and Barnett (2016) identify engaging in personal psychotherapy on a periodic basis as a self-care strategy and as a form of positive self-development. Personal therapy can be one of the ways to maintain self-care and competence throughout one’s career. We recommend that you involve yourself in therapeutic experiences that increase your availability to your clients. There are many ways to accomplish this goal: individual therapy, group counseling, consultation with trusted colleagues, continuing education (especially of an experiential nature), keeping a personal journal, and reading. Other less formal avenues to personal and professional development are reflecting on and evaluating the meaning of your work and life, remaining open to the reactions of significant people in your life, traveling to experience different cultures, taking a yoga or a meditation class, practicing mindfulness in daily living, engaging in spiritual activ- ities, enjoying physical exercise, spending time with friends and family, and being involved with a hobby. The common theme throughout these activities is that they focus on your own self-care and physical and emotional health. Taking care of your- self is paramount in helping you guide others through their therapeutic journey.

Experiential Learning Toward Self-Understanding

Experiential learning is a basic component of many counseling programs, provid- ing students with the opportunity to share their values, life experiences, and per- sonal concerns in a peer group. Many training programs in counselor education recognize the value of having students participate in personal-awareness groups with their peers. Such a group experience does not necessarily constitute group therapy; however, it can be therapeutic in that it provides students with a frame- work for understanding how they relate to others and can help them gain a deeper insight into their shared concerns. A group can be set up specifically for the explo- ration of personal concerns, or such exploration can be made an integral part of training and supervision. Whatever the format, students will benefit most if they are willing to focus on themselves personally and not merely on their clients. Begin- ning counselors tend to focus primarily on client dynamics, as do many supervi- sors and counselor educators. Being in a group affords students the opportunity to explore questions such as these: “How am I feeling about being a counselor?” “How do I assess my relationships with my clients?” “What reactions are being evoked in me as I work with clients?” “Can I be open with my own reactions as a counselor?” “Am I willing to appropriately self-disclose in my work as a coun- selor?” By being personally invested in their own therapeutic process, students can use the training program as an opportunity to expand their abilities to be helpful.

It is important for counselor educators and supervisors to clarify the fine line between training and therapy in the same way that fieldwork agencies must main- tain the distinction between training and service. Although these areas overlap, it is clear that the emphasis for students needs to be on training in both academic and clinical settings, and it is the educator’s and supervisor’s responsibility to maintain that emphasis. It is essential that students be informed at the outset of the program of any requirement for personal exploration and self-disclosure. Students have a right to know about the nature of courses that involve experiential learning. The informed consent process is especially important in cases where the instructor also functions in the role of the facilitator of a group experience. We discuss this topic at greater length in Chapters 7, 8, and 9.

The Case of a Required Therapeutic Group

Miranda is a psychologist in private practice hired by the director of a graduate program in counseling psychology to lead an experiential group. she assumes that the students have been informed about this therapeutic group, and she is given the impression that students are eagerly looking forward to it. When she meets with the students at the first class, however, she encounters a great deal of frustration. they express resentment that they were not told that they would be expected to participate in a therapeutic group. some students fear negative consequences if they do not participate.

if you were a student in this group, how might you feel and react?
is it ever ethical to mandate self-exploration experiences?
the students knew from their orientation and the university’s literature that this graduate program included some form of self-exploration. in your opinion, was this disclosure suffi- cient for informed consent?
if you were Miranda, what would you do in this situation? how would you deal with the students’ objections?

Commentary. informing students prior to entering the program that self-exploration will be part of their training only minimally satisfies the requirement for informed consent. students have a right to be informed about every aspect of the experiential group: the rationale for the group, issues pertaining to confidentiality, and their rights and responsibilities regarding participation in experiential activities. shumaker, Ortiz, and brenninkmeyer (2011) recommend that experiential groups include a detailed informed consent process and teach students what constitutes appropriate self-disclosure in such a group. clear guidelines must be established so students know what their rights and responsibilities are. in addition to this general orien- tation by the program, each instructor (in this case, Miranda) has an obligation to ensure that students have been properly informed about these expectations and requirements. Miranda has an obligation to ensure that group participation is genuinely voluntary and, if not, that the experience is clearly related to program training objectives. Miranda could explain to trainees the value of an experiential group in terms of gaining insights into their personal dynamics, such as potential areas of countertransference. by identifying areas that can lead to counter- transference, trainees are in a position to do further work in their own therapy outside of the group. in our view, Miranda needs to provide an opportunity for students to share their con- cerns at the initial group meeting. she needs to provide a rationale for experiential learning and explore with students how participation in an experiential group can equip them with the awareness and skills to become effective group facilitators. •

Personal Therapy During Training

Studies on Personal Therapy for Trainees Personal therapy can be a valuable component for the growth of clinicians. In many theoretical traditions, and par- ticularly in the psychodynamic tradition, personal therapy is deemed essential in the development of therapists (Ronnestad, Orlinsky, & Wiseman, 2016). An assumption of many training programs is that personal counseling should be a requirement for students planning to go into the counseling profession. Gold and Hilsenroth (2009) demonstrated that graduate clinicians who had personal ther- apy felt more confident in their role and delivered treatments that were twice as long as those of graduate clinicians who did not experience personal therapy. Their study also found that graduate clinicians who had experienced personal therapy developed strong agreement with their clients on the goals and tasks of treatment. Dearing, Maddux, and Tangney (2005) emphasized the responsibil- ity of faculty, supervisors, and mentors in educating trainees about appropriate pathways to self-care and prevention of impairment. Students are more likely to seek personal therapy when faculty members convey favorable and supportive attitudes about student participation in therapy. Faculty can provide modeling for students by appropriately sharing their own experiences with therapy dur- ing their training and later. Dearing and colleagues indicate that confidentiality issues, general attitudes about therapy, and the importance of personal therapy for professional development were key predictors for trainees seeking their own therapy. They suggest that students consider the potential benefits, both person- ally and professionally, of psychotherapy during their training, including alle- viation of personal distress, a means of gaining insight into being an effective therapist, and development of healthy and enduring self-care habits. Ronnestad and colleagues (2016) report that studies pertaining to the influence of psycho- therapy on therapists as people include “positive increments in self-awareness, self-knowledge, self-understanding, self-care, and self-acceptance as well as reduction in symptoms and improved relationships and personal growth gen- erally” (p. 230). Furthermore, personal therapy can teach us more about the pro- fession as we observe and learn new strategies by participating as a client. Our capacity for empathy increases as we begin to understand how challenging it may be for clients to come to us and the courage it takes to share intimate details with a helping professional.

Counselor education programs would do well to work with therapy pro- viders outside the program or at their university’s counseling center to offer psychological services to graduate students in their programs. Because of the ethical problems of counselor educators and supervisors providing therapy for their students and supervisees, faculty members have an obligation to become advocates for their students by identifying therapeutic resources students can afford. Some training programs provide a list of practitioners who are willing to see students at a reduced fee. There are both practical and ethical reasons to prefer professionals who are not part of a program and who do not have any evaluative role in the program when providing psychological services for train- ees. Practitioners from the community could be hired by a counselor-training program to conduct therapeutic groups, or students might take advantage of

either individual or group counseling from a community agency, a college coun- seling center, or a private practitioner.

Reasons for Participating in Personal Psychotherapy In your own therapy you can take an honest look at your motivations for becoming a helper. You can explore how your needs influence your actions, how you use power in your life, and what your values are. Your appreciation for the courage your clients show in their therapeutic journey will be enhanced through your own experience as a client. In addition, we believe personal therapy is a valuable form of ongoing self-care. As therapists, we are often in the role of giver; to preserve our vitality, we need to create spaces in which the “giver” can be supported. Personal therapy affords opportunities for you to learn how to establish and maintain a working alliance and how to deal with the challenges and uncertainties involved in therapeutic work (Ronnestad et al., 2016). As Wise and Barnett (2016) state: “Good personal therapy is good not only for therapists as clients but also, in the long run, for the therapists’ clients” (p. 231).

When students are engaged in practicum, fieldwork, and internship experi- ences and the accompanying individual and group supervision sessions, the fol- lowing personal themes may surface:

A tendency to tell people what to do • A strong need to alleviate clients’ pain • Discomfort with intense emotion • A need for quick solutions • A fear of making mistakes • An intense need to be recognized and appreciated • A tendency to assume too much responsibility for client change • A fear of doing harm, however inadvertently • A tendency to deny or not recognize client problems when they activate your

own problems • A preoccupation with winning approval and for clients and supervisors to

like you • An internal focus on what you should say or do next rather than on what the

client is saying and experiencing

When trainees begin to practice psychotherapy, they sometimes become aware that they are taking on a professional role that resembles the one they played in their family. They may recognize a need to preserve peace by becoming caretakers. When trainees become aware of concerns such as these, therapy can provide a safe place to explore them. Trainees are likely to struggle with creating a sustainable balance between caring for clients and caring for others. Personal therapy can help trainees become aware of the interplay between care of the self and care of the other (Wise, Hersh, & Gibson, 2012). It is important for graduate programs to provide a safe context for training, and the rights and welfare of students must be con- sidered. However, we believe counselor educators can go too far in the direction of protecting the rights of counselor trainees, for example, by not requiring any form of self-exploratory experience as part of their training program. Educators must also be concerned about protecting the public. In Chapter 8 we provide some

real cases that elaborate on this point. One way to ensure that clients will get the best help available is to prepare students both academically and personally for the tasks they will face as practitioners.

The ethics codes of various professions state that it is not appropriate for supervisors to function as therapists for their supervisees. However, good super- vision is therapeutic in the sense that the supervisory process involves assisting supervisees in identifying their personal problems so that clients are not harmed. Both trainees and experienced therapists must recognize and deal effectively with their countertransference, which can be explored in personal therapy.

Consider the situation of a therapist who himself is a veteran with a disability working with other disabled veterans. He may be experiencing a great deal of anger and frustration over the lack of attention to the basic needs of his clients, but he may be suffering from the same neglect. As a result, the therapist’s personal problems may get in the way of focusing on his clients’ needs. Countertransfer- ence reactions also need to be considered for addiction therapists, especially for therapists who are in recovery themselves. For example, in inpatient substance abuse treatment programs, the daily intensity of treatment may affect both client and therapist. In this kind of environment, ongoing supervision is required. Par- ticipating in one’s own recovery group is often expected, and personal therapy can be most useful.

When practitioners have been found guilty of a violation, some licensing boards require therapy as a way for practitioners to recognize and monitor their countertransference. We think this provides a rationale for psychotherapy for both trainees and practitioners as a way of reducing the potential negative con- sequences of practicing psychotherapy. On an ongoing basis, therapists must rec- ognize and deal with their personal issues and their potential impact on clients. Therapists should seek personal therapy before distressing life situations lead to burnout and harm to clients (Barnett, Johnston, & Hillard, 2006).

Ongoing Therapy for Practitioners

Experienced practitioners can profit from therapy that provides them with oppor- tunities to reexamine their beliefs and behaviors, especially as these factors pertain to their effectiveness in working with clients. In a study examining the personal therapy experiences of more than 4,000 psychotherapists of diverse theoretical ori- entations in more than a dozen countries, Orlinksy and Ronnestad (2005) found that more than 88% rated the experience as positive. Another large-scale study (3,995 psychotherapists in six English-speaking countries) found that personal therapy among therapists is a common practice and that it is considered bene- ficial (Orlinsky, Schofield, Schroder, & Kazantzis, 2011). In a meta-analysis, more than three-quarters of therapists across multiple studies believed that their per- sonal therapy had a strong positive influence on their development as clinicians (Orlinsky, Norcross, Ronnestad, & Wiseman, 2005). Norcross (2005) has gathered self-reported outcomes of personal therapy that reveal positive gains in multiple areas, including self-understanding, self-esteem, work functioning, social life, emotional expression, and intrapersonal conflicts. The most frequent long-lasting benefits to practitioners pertained to interpersonal relationships and the dynamics

of psychotherapy. Some of the lessons learned are the centrality of warmth, empa- thy, and the personal relationship; having a sense of what it is like to be a ther- apy client; the need for patience in psychotherapy; and learning how to deal with transference and countertransference.

Transference and Countertransference

Although the terms transference and countertransference derive from psychoanalytic theory, they are universally applicable to many other approaches to counseling and psychotherapy, and to relationships in general. These concepts refer to the client’s general reactions to the therapist and to the therapist’s reactions to the client. The therapeutic relationship can intensify the reactions of both client and therapist, and how practitioners handle both their own feelings and their clients’ feelings will have a direct bearing on therapeutic outcomes. If a therapist’s own feelings are not attended to, the client’s progress will most likely be impeded. Therefore, this matter has implications from both an ethical and a clinical perspective.

Transference: The “Unreal” Relationship in Therapy

Transference is the process whereby clients project onto their therapists past feel- ings or attitudes they had toward their caregivers or significant people in their lives. Transference is understood as having its origins in early childhood and con- stitutes a repetition of past themes in the present. How the clinician deals with a client’s transference is crucial. If therapists are unaware of their own dynamics, they may miss important therapeutic issues and be unable to help their clients resolve the feelings they are bringing into the therapeutic relationship.

The client’s feelings are rooted in past relationships, but those feelings are now felt and directed toward the therapist. This pattern causes a distortion in the way clients perceive and react to the therapist. By bringing these early memories to the relationship with the therapist, clients are able to gain insight into how their past relationships with significant others have resulted in unresolved conflicts that influence their present relationships. Safran and Kriss (2014) explain how thera- pists can assist clients in understanding how their past plays out in the present: “Because transference involves a type of reliving of clients’ early relationships in the present, the therapist’s observations and feedback can help them to see, under- stand, and appreciate their own contributions to the situation” (p. 36).

Transference is not a catch-all concept intended to explain every feeling cli- ents express toward a therapist. Many reactions clients have toward counselors are based on the here-and-now style the counselor exhibits. If a client expresses anger toward you, it may or may not be transference. If a client expresses positive reactions toward you, likewise, these feelings may or may not be genuine; dismiss- ing them as infantile fantasies can be a way of putting distance between yourself and your client. It is possible for therapists to err in either direction—being too quick to explain away negative feelings or too willing to accept positive feelings. To understand the real import of clients’ expressions of feelings, therapists have to actively work at being open, vulnerable, and honest with themselves. Although

ethical practice implies that therapists are aware of the possibility of transference, they also need to be aware of the potential of discounting the genuine reactions their clients have toward them.

Let’s examine two brief, open-ended cases in which we ask you to imagine yourself as the therapist. How do you think you would respond to each client? What are your own reactions?

The Case of Jasmine

jasmine is extremely dependent on you for advice in making even minor decisions. it is clear that she does not trust herself and often tries to figure out what you might do in her place. she asks you personal questions about your marriage and your family life. she has elevated you to the position of someone who makes wise choices, and she is trying to emulate you. at other times she tells you that her decisions typically turn out to be poor ones. consequently, when faced with a decision, she vacillates and becomes filled with self-doubt. although she says she realizes that you cannot give her the answers, she keeps asking you what you think about her decisions.

how would you deal with jasmine’s behavior?
how do you interpret jasmine’s attachment to you?
how would you respond to her questions about your private life?
can you normalize what jasmine is feeling without directly self-disclosing?
if many of your clients expressed the same thoughts as jasmine, is there anything in your counseling style that you may need to examine?
Would you consider any cultural factors in evaluating jasmine’s behavior?

Commentary. When clients ask you questions about your private life, consider what has prompted these inquiries. the client’s reasons for asking the questions may be more impor- tant than your answers and can offer useful clinical material to be explored. you may not be inappropriately fostering dependence in jasmine, but you will want to explore the dynamics of jasmine’s need to get your opinion. consider looking at any potential cultural influences in jasmine’s style of relating to you as a person of authority. above all, therapists are ethically obligated to promote client autonomy. if you find yourself offering jasmine advice, it is time to look within yourself and examine your possible contribution to her dependency. •

The Case of Marisa

Marisa informs you that she terminated therapy with a prior therapist “because he was unable to understand or help her.” she tends to project blame on others and does not take respon- sibility for her problems. Marisa tells you that she is disappointed in the way her counseling is going with you. she doesn’t know if you care very much about her. she would like to be special to you, not “just another client.”

how would you deal with Marisa’s expectations?
Would you explore with Marisa her experience with her prior therapist? explain.
can you see a potential ethical issue in the manner in which you would respond to her?
Would you tell Marisa how she affects you? Why or why not?
how could you address the issues underlying Marisa’s comments without responding directly to what she is asking?

Commentary. Marisa’s desire to redefine the therapy process and become special in your eyes should be explored. a therapist with a strong need to please or to be a caretaker may inad- vertently promote dependence or role-blurring. if you go out of your way to make Marisa feel special, consider your reasons for doing so. Marisa’s desire to feel special with you likely has roots in other relationships in her life. it is crucial to assist Marisa in exploring why feeling “special” is a particular need for her interpersonally rather than being too quick to reassure her. •

Countertransference: Ethical Implications

LO3

So far we have focused on the transference feelings of clients toward their counsel- ors, but counselors also have emotional reactions to their clients, some of which may involve their own projections. It is not possible to deal fully here with all the possible nuances of transference and countertransference. Instead, we focus on the ethical implications of improperly handling these reactions in the therapeutic relationship.

In the past, countertransference was considered as any projections by ther- apists that distort the way they perceive and react to a client. This phenomenon occurs when there is inappropriate affect, when clinicians respond in highly defensive ways, or when they lose their objectivity in a relationship because their own conflicts are triggered. In other words, the therapist’s reaction to the client is intensified by the therapist’s own experience. Freud considered a therapist’s countertransference as an obstacle to therapy; the therapist’s task was to work through these reactions in supervision and personal therapy. In current practice, countertransference is viewed differently. It refers to all of the therapist’s reactions, not only to the client’s transference reactions. In this broader perspective, counter- transference involves the therapist’s total emotional response to a client includ- ing feelings, associations, fantasies, and fleeting images (Safran & Kriss, 2014; Wolitzky, 2011). Examples of countertransference reactions include the arousal of guilt from unresolved personal problems, inaccurate interpretations of the client’s dynamics because of projection on the therapist’s part, experiencing an impasse with a client and frustration over not making progress, and impatience with a client (Norcross & Guy, 2007).

Manifestations of Countertransference Countertransference can show itself in many ways, as has been described by Watkins (1985) in his classic thought- provoking article. Each example in the following list presents potential ethical and clinical issues because the therapist’s clinical work can be obstructed by counter- transference reactions if these reactions are not managed:

Being overprotective with a client can reflect a therapist’s fears. A counselor’s unresolved conflicts can lead him or her to steer a client away from those areas that open up the therapist’s own pain. Such counselors may treat those clients as fragile and infantile.

In your personal life, are you aware of reacting to certain people in overpro- tective ways?
Do you find that you allow others to experience their pain, or do you have a tendency to want to move away from their pain very quickly or offer advice to relinquish their pain?

. Treating clients in benign ways may stem from a counselor’s fear of clients’ anger. To guard against this anger, the counselor creates a bland counseling atmosphere. This tactic results in superficial exchanges.

Are you aware of how you typically react to anger directed at you? • What do you need to do when you become aware that your exchanges are

primarily superficial?

Rejecting a client may be based on the therapist’s perception of the client as needy and dependent. Instead of moving toward the client to work with him or her, the counselor may back away from the client.

How do you react to unmotivated clients? • Do you find yourself wanting to create distance from certain types of behavior

in people? • Do you find yourself clinging to clients with certain types of behavior? • What can you learn about yourself by looking at those people whom you are

likely to reject?

Needing constant reinforcement and approval can be a reflection of countertrans- ference. Just as clients may develop an excessive need to please their therapists, therapists may have an inordinate need to be reassured of their effectiveness. When therapists do not see immediate positive results, they may become discour- aged, angry, ambivalent, or anxious.

Do you need to have the approval of your clients? How willing are you to challenge clients even at the risk of being disliked?
How effectively are you able to challenge others in your own personal life? What does this behavior tell you about you as a therapist?

Seeing yourself in your clients can be another form of countertransference. This is not to say that feeling close to a client and identifying with that person’s strug- gle is necessarily countertransference. However, beginning therapists often iden- tify with clients’ problems to the point that they lose their objectivity and become overly compassionate, which has ethical and clinical implications. Therapists may become so lost in the client’s world that they are unable to separate their own feelings or to create healthy boundaries between work and their personal life. If the counselor becomes too emotionally engaged when experiencing the client’s emotions during session, the client may try to take on the caregiver role for the therapist.

In your personal life, have you ever found yourself so much in sympathy with others that you could no longer be of help to them? What does that tell you about you?
From an awareness of your own dynamics, list some personal traits of clients that could elicit overidentification on your part.

Developing sexual or romantic feelings toward a client can exploit the vulnerable position of the client. Seductive behavior on the part of a client can easily lead to the adoption of a seductive style by the therapist, particularly if the therapist is

unaware of his or her own dynamics and motivations. It is natural for therapists to be more at ease with some clients than others, and these feelings do not necessar- ily mean therapists cannot counsel these clients effectively. More important than the mere existence of such feelings is the manner in which therapists deal with them. The possibility that therapists’ sexual feelings and needs might interfere with their work is one important reason therapists should experience their own therapy when starting to practice and should consult other professionals when they encounter difficulty due to their feelings toward certain clients.

How would you handle sexual feelings toward a client? What would you do if you found yourself frequently being sexually attracted to your clients?

nity to give advice places therapists in a superior position, and they may delude themselves into thinking that they do have answers for their clients. Some thera- pists experience impatience with their clients’ struggles toward autonomous deci- sion making. Such counselors may engage in excessive self-disclosure, especially by telling their clients how they have solved a particular problem for themselves. In doing so, the focus of therapy shifts from the client’s struggle to the needs of the counselor. Providing advice as a regular intervention can be counterproductive. Even if a client has asked for advice, there is every reason to question whose needs are being served when a therapist falls into advice giving.

With family members and friends do you succumb to advice giving? If so, how does this affect your relationships with them?
Are there times when advice is warranted? If so, when? How would a client’s culture need to be considered regarding the practice of giving advice?

Developing a social relationship with clients may stem from countertransference, especially if it is acted on while therapy is taking place. Clients occasionally let their therapist know that they would like to develop a closer relationship than is possible in the limited environment of the office. Mixing personal and professional relationships can destroy the therapeutic relationship and could lead to a malprac- tice suit. Ask yourself these questions:

Will my own needs for preserving these friendships with clients interfere with my therapeutic responsibilities and defeat the purpose of therapy?
Will I be able to remain objective and continue to challenge my clients if I develop a friendship with them?
Will my client be able to return to therapy if we form a social relationship after termination?

Effective Management of Countertransference Reactions Countertrans- ference can be either a constructive or a destructive element in the therapeutic relationship. A therapist’s countertransference may illuminate some significant dynamics of a client. A client may actually be stimulating reactions in a therapist by the ways in which he or she makes the practitioner into a key figure from the past. The fact that the client may have stimulated the countertransference

in the therapist does not make this a client’s problem. The key here is how the therapist responds. Clinicians who recognize these patterns and are able to manage their own countertransference reactions can eventually help the client change old dysfunctional themes. Hayes, Gelso, and Hummel (2011) present the following guidelines for therapeutic practice for working effectively with countertransference:

Countertransference can greatly benefit the therapeutic work if clinicians monitor their feelings and use their responses as a source for understanding clients and helping clients to understand themselves.
The ability of therapists to gain self-understanding and establish appropri- ate boundaries with clients is fundamental to managing and effectively using their countertransference reactions.
Personal therapy and clinical supervision can be especially helpful to ther- apists in understanding how their internal reactions influence the ther- apy process and how to use these countertransference reactions to assist clients.

Therapists must develop some level of objectivity and guard against reacting defensively and subjectively when they encounter intense feelings expressed by their clients.

Countertransference: Clinical Implications

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Countertransference becomes problematic when it is not recognized, moni- tored, and managed. Destructive or harmful countertransference occurs when a counselor’s own needs or unresolved personal conflicts become entangled in the therapeutic relationship, obstructing or destroying a sense of objectivity. In this way, countertransference becomes an ethical issue, as is illustrated in the following cases.

The Case of Lucia

Lucia is a Latina counselor who has been seeing thelma, who is also a Latina. thelma’s pre- senting problem was her depression related to an unhappy marriage. her husband, an alco- holic, refuses to come to counseling with thelma. she works full time in addition to caring for their three children. Lucia is aware that she is becoming increasingly irritated and impatient with her client’s “passivity” and lack of willingness to take a strong stand with her husband. During one of the sessions, Lucia says to thelma: “you are obviously depressed, yet you seem unwilling to take action to change your situation. you have been talking about the pain of your marriage for several months and tend to blame your husband for how you feel. you keep saying the same things, and nothing changes. your husband refuses to seek treatment for himself or to cooperate with your therapy, yet you are not doing anything to change your life for the better.” Lucia says this with a tinge of annoyance. thelma seems to listen but does not respond. When Lucia reflects on this session, she becomes aware that she has a tendency to be more impatient and harsh with female clients from her own culture, especially over the issue of passivity. she realizes that she has not invited thelma to explore ways that her cultural background and socialization have influenced her decisions. in talking about this case with a supervisor, Lucia explores why she seems to be triggered by women like thelma.

she recognizes that she has a good deal of unfinished business with her mother, whom she experienced as extremely passive.

if you were Lucia’s supervisor, what would you most want to say to her?
both the therapist and the client share a similar cultural background. to what extent does that need to be explored?
if you were Lucia’s supervisor, would you suggest self-disclosure as a way to help her client? What kind of therapist disclosure might be useful? Do you see any drawbacks to therapist self-disclosure in this situation?
because of Lucia’s recognition of her countertransference with passive women, would you suggest that she refer thelma to another professional? Why or why not?
What reactions do you have to the manner in which Lucia dealt with thelma? could any of Lucia’s confrontation be viewed as therapeutic? What would make her confrontation nontherapeutic?
Was Lucia remiss in not attending to the alcohol problem of the husband?
could Lucia’s recognition of her own struggles with her mother facilitate her work with women like thelma?
What are the ethical ramifications in this case?
if your unresolved personal problems and countertransference reactions were interfering with your ability to work effectively with a particular client, what actions would you take?

Commentary. regardless of how self-aware and insightful counselors are, the demands of practicing therapy are multifaceted. the emotionally intense relationships counselors develop with clients can be expected to tap into their own unresolved conflicts. because countertrans- ference may be a form of identification with the client, the counselor can easily get lost in the client’s world and be of little therapeutic value. in the case of Lucia, the ethical course of action we suggest would be for Lucia to involve herself in personal therapy to deal with her own unresolved personal issues. supervision would enable her to monitor her reactions to certain behaviors of clients that remind her of aspects in herself that she struggles with.

When countertransference interferes with good counseling work, ethical practice requires that practitioners pay attention to their emotional reactions to their clients, that they attempt to understand such reactions, and that they do not inflict harm because of their personal prob- lems and conflicts. Personal therapy can provide us with a deeper self-understanding, which increases our ability to stay focused on the needs of our clients. •

The Case of Ruby

ruby is counseling henry, who expresses extremely hostile feelings toward homosexuals and toward people who have contracted aiDs. henry is not coming to counseling to work on his feelings about gay people; his primary goal is to work out his feelings of resentment over his wife, who left him. in one session he makes derogatory comments about gay people. he thinks they are deviant and that it serves them right if they do get aiDs. ruby’s son is gay, and henry’s prejudice affects her emotionally. she is taken aback by her client’s comments, and she finds that his views are getting in the way as she attempts to work with him. her self-dialogue has taken the following turns:

i should tell henry how he is affecting me and let him know i have a son who is gay. if i don’t, i am not sure i can continue to work with him.
i think i will express my hurt and anger to a colleague, but i surely won’t tell henry how he is affecting me. nor will i let him know i am having a hard time working with him.

henry’s disclosures get in the way of my caring for him. Perhaps i should tell him i am both- ered deeply by his prejudice but not let him know that i have a gay son.

because of my own countertransference, it may be best that i refer him without telling him the reason i am having trouble with him.
i want to explore why henry continues to bring up his reactions to gay people rather than addressing the personal concerns he said brought him to therapy.

Which of ruby’s possible approaches to henry do you find yourself most aligned with? if ruby came to you as a colleague and wanted to talk about her reactions and the course she should take with henry, what would you say to her? in reflecting on what you might tell her, consider these issues:

is it ethical for ruby to work on a goal that her client has not brought up?
to what degree would you encourage ruby to be self-disclosing with henry? What should she reveal of herself to him? What should she not disclose? Why?
is it ethical for ruby to continue to see henry without telling him how she is affected by him?

Commentary. all of ruby’s self-dialogue statements are potential avenues for productive exploration. because of her own countertransference, ruby is experiencing difficulty in refo- cusing henry on his stated goal for therapy. if she cannot get beyond her reactions, it will be difficult for her to be therapeutic with him. ruby may or may not choose to tell henry, without going into too much detail, that he is having an effect on her personally. such self-disclosures should always be for the client’s benefit, not the therapist’s. ruby can acknowledge her reac- tions without indulging herself in them. if henry’s comments become abusive, or if ruby feels she can no longer be therapeutic, ruby should consider an appropriate referral. if henry were our client, we would approach him with a sense of interest over his focusing his resentment on gay people when he declared that his goal for therapy is to deal with his resentment toward his ex-wife. •

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Client Dependence

Many clients experience a period of dependence on counseling or on their coun- selor. This temporary dependence is not necessarily problematic, especially dur- ing the early phase of therapy. Some clients see the need to consult a professional as a sign of weakness. When these clients finally allow themselves to need others, their dependence does not necessarily mean that the therapist is unethical. There are ethical implications, however, when counselors encourage and promote depen- dency. This may happen for any number of reasons. Counselors may keep clients longer than necessary for financial reasons. Some therapists in private practice fail to challenge clients who show up and pay regularly, even though they appear to be stymied. Clinicians can foster dependence in their clients in subtle ways. When clients insist on answers, these counselors may readily tell them what to do. Dependent clients can begin to view their counselors as having great wisdom; therapists who have a need to be perceived in this way collude with their clients in keeping them dependent.

When therapists offer quick solutions to clients’ problems, they could impede clients’ empowerment. With the growth of managed care in the United States as

n alternative to traditional fee-for-service delivery systems, the client–counselor relationship is changing in many ways. In the relatively brief treatment and the restricted number of sessions allowed in most managed care plans, client depen- dence is often less of an issue than it might be with long-term therapy. However, even in short-term, problem-oriented therapy aimed at solutions, clients can develop an unhealthy dependence on their therapist. When this happens, it is the therapist’s duty to deal with it therapeutically and not to blame the client.

Whether therapists are encouraging dependence in clients is often not clear- cut. To help you to think of possible ways that you might foster dependence or independence in your clients, consider the following case.

The Case of Blake

blake, a young counselor, encourages his clients to text him at any time. he expects to be on call at all times. he frequently lets sessions run overtime, lends money to clients when they are destitute, and devotes many more hours to his job than are required. he says the more he can do for people, the better he feels.

how might blake’s style of counseling either help or hinder a client?
Do you see any potential ethical issues in the way blake treats his clients?
in what ways could blake’s style be keeping his clients dependent on him?
can you identify with blake in any ways? Do you see yourself as potentially needing your clients more than they need you?
in what cultural contexts might blake’s style be viewed positively?

Commentary. from our perspective, the overriding ethical question is whether blake’s behav- iors toward clients demonstrate beneficence or maleficence. in other words, is blake really helping his clients? We also wonder about blake’s boundaries with his clients. some of blake’s behaviors are inconsistent with promoting client autonomy and seem aimed more at meeting blake’s own needs. We want to be careful not to judge blake’s enthusiasm and devotion to his work in a negative way, but blake could be at high risk for burnout or empathy fatigue based on this high level of involvement with his clients. •

Delaying Termination as a Form of Client Dependence

Most professional codes have guidelines that call for termination whenever fur- ther therapy will not bring significant gains, but some therapists have difficulty doing this. They run the risk of unethical practice because of either financial or emotional needs. Therapists who become angry with clients when they express a desire to terminate therapy are showing signs of problematic countertransference. Obviously, termination cannot be mandated by ethics codes alone; it rests on the honesty of the therapist and the willingness to include the client in a collaborative discussion about the client’s readiness for ending therapy. Termination of a pro- fessional relationship can be a complex process, and problems often occur during termination. A successful termination calls for a blending of clinical, practical, and ethical factors that become the foundation for the termination process (Davis & Younggren, 2009).

Rather than viewing termination as a discrete event that marks the end of therapy, it is best viewed as a process for ending therapy over a period of time. Open-ended treatments over a long period of time without clear and identifiable goals are especially difficult to end. In our view, the ultimate sign of an effective therapist is his or her ability to help clients reach a stage of self-determination wherein they no longer need a therapist. Essentially, it is our goal to work our- selves out of a job by empowering our clients and helping them achieve their goals in therapy.

Most of the ethics codes state that practitioners should terminate services to clients when such services are no longer required, when it becomes reasonably clear that clients are not benefiting from therapy, or when the agency or institution limits do not allow provision of further counseling services. Apply the general spirit of these codes to these questions:

How would you know when services are no longer required? • What criteria would you use to determine whether your client is benefiting

from therapy? • What would you do if your client feels he or she is benefiting from therapy, but

you don’t see any signs of progress? • What would you do if you are convinced that your client is coming to you

seeking friendship and not really for the purpose of changing? • What are the ethical ramifications if your agency limits the number of sessions yet your client is clearly benefiting from counseling? What if termination is

likely to harm the client?

Imagine yourself as the therapist in the following two cases. Ask yourself what you would do and why if you were confronted with the problems described.

The Case of Jiwoo

after five sessions jiwoo asks: “Do you think i’m making any progress in solving my problems? Do i seem any different to you now than i did 5 weeks ago?” before you give him your impres- sions, you ask him to answer his own questions. he replies: “Well, i’m not sure whether coming here is doing that much good. i suppose i expected resolutions to my problems before now, but i still feel anxious and depressed much of the time. it feels good to come here, and i usually continue thinking about what we discussed after our sessions, but i’m not coming any closer to decisions. sometimes i feel certain this is helping me, and at other times i wonder whether i’m just fooling myself.”

What are some pros and cons of your answering jiwoo’s question?
What criteria can you employ to help you and your client assess the value of counseling for him? are there techniques from specific theories that could help jiwoo measure his growth? What clinical assessments might assist in measuring his growth?
Does the fact that jiwoo continues to think about his session during the rest of the week indicate that he is probably getting something from counseling? Why or why not?

Commentary. the fact that jiwoo asks this question is a positive sign for us because it shows that he is involved in the outcomes of his own therapy. this is an opportunity for you to explore jiwoo’s expectations and his goals for treatment. avoid being defensive with him and explain

how the therapeutic process works. ask about specific aspects of his therapy that he has found helpful and not helpful. informed consent as an ongoing process rather than a one-time event, and jiwoo’s question provides another opportunity for you to extend his knowledge about the therapeutic process. •

The Case of Enjolie

enjolie has been coming to counseling for some time. When you ask her what she thinks she is getting from the counseling, she answers: “this is really helping. i like to talk and have some- body listen to me. you are the only friend i have and the only one who really cares about me. i suppose i really don’t do that much outside, and i know i’m not changing that much, but i feel good when i’m here.”

is it ethical for you to continue the counseling if enjolie’s main goal seems to be the “pur- chase of friendship”? Why or why not?
Would it be ethical to terminate enjolie’s therapy without exploring her need to see you?
how do you imagine enjolie would perceive your suggestions to terminate therapy? What clinical issues would you need to keep in mind?
Would it be ethical for you to continue to see enjolie if you were convinced that she was not making any progress?

Commentary. We might ask enjolie to describe what brought her to therapy and help her to define her current goals for treatment. We would point out that therapy is not the place to make friends with us; it is a chance for her to learn how to make friends in her outside life. We could explore with her what she is doing to find people who will listen to her and what she could do to establish friendships. We would encourage enjolie to focus on the extent to which she is achieving her goals outside of therapy. if we were convinced that enjolie was not benefiting from individual therapy, we would consider referring her to a therapy group as the focus of this modality is on interpersonal relationships. •

Stress in the Counseling Profession The Hazards of Helping

Helping professionals engage in work that can be demanding, challenging, and emotionally taxing. Students often are not given sufficient warning about the haz- ards of the profession they are about to enter. Many counselors in training look forward to a profession in which they can help others and, in return, feel a deep sense of self-satisfaction. Students may not be told that the commitment to self- exploration and to inspiring this search in clients can be fraught with difficulties. The counselor, as a partner in the therapeutic journey, can be deeply affected by a client’s pain. Effective practitioners use their own life experiences and personal reactions to help them understand their clients and as a method of working with them. As you will recall, the process of working therapeutically with people can open up personal issues in the therapist’s life, and countertransference may result. If you find yourself struggling, seek consultation to ensure that the client’s best interests are at the forefront and that your practice is ethically sound.

Graduate training programs in the helping professions need to prepare stu- dents for the work that lies ahead for them. Self-care education should start at the beginning of a graduate program to prevent future problems in students’ careers. Emphasize the importance of self-care and encourage students to create a self-care action plan for their graduate school journey. This action plan could be revisited throughout their program of study and again when students begin their clinical experience and prepare to enter the profession. Self-care principles and practices extend beyond graduate school to encompass the entire span of one’s career (Wise & Barnett, 2016). If students are not adequately prepared, they may be especially vulnerable to early disenchantment, distress, and burnout due to unrealistic expectations. Training programs have an ethical responsibil- ity to design strategies to assist students in dealing effectively with job stress, in preventing burnout, and in emphasizing the role of self-care as a key fac- tor in maintaining vitality. Ideally, the faculty in graduate training programs will model self-care attitudes and practices for students. Newsome, Waldo, and Gruszka (2012) state that learning to deal with stress to prevent burnout and compassion fatigue is a critical aspect of professional development. They con- tend that training programs do not do enough to educate trainees about the negative effects of job-related stress, how to prevent burnout, or how to develop self-compassion. Newsome and colleagues’ study offers compelling evidence for including mindfulness groups as part of the training program for counsel- ing students: “Significant and sustained gains in stress reduction, mindfulness, and self-compassion argue that mindfulness groups offer significant benefits for future helping professionals” (p. 309).

Stress Caused by Being Overly Responsible

When therapists assume full responsibility for their clients’ lack of progress, they are not helping clients to be responsible for their own therapy. Practitioners who accept too much responsibility sometimes experience their clients’ stress as their own. It is important to recognize when this is happening. Signs to look for are irritability and emotional exhaustion, feelings of isolation, abuse of alcohol or drugs, having a relapse from recovery, reduced personal effectiveness, indeci- siveness, compulsive work patterns, drastic changes in behavior, and concerned feedback from friends or partners. Stress is an event or a series of events that leads to strain, which can result in physical and psychological health problems. To assess the impact of stress on you both personally and professionally, reflect on these questions:

To what degree are you able to recognize your problems? • What steps do you take in dealing with your problems? • Do you practice strategies for managing your stress? • To what degree are you taking care of your personal needs in daily life? • Do you listen to your family, friends, and colleagues when they tell you that

they are seeing signs of severe stress? • Are you willing to ask for help? If so, from whom? • Are you willing to make changes to more effectively manage your stress?

Sources of Stress

In his book Empathy Fatigue, Stebnicki (2008) writes about the stress generated by listening to the multiple stories of trauma that clients bring to therapy. These stories are saturated with themes of grief, loss, anxiety, depression, and traumatic stress. When these stories mirror therapists’ own personal struggles too closely, empathy fatigue may result, which shares some similarities with other fatigue syndromes such as compassion fatigue, secondary traumatic stress, vicarious traumatization, and burnout. The symptoms of empathy fatigue are common to professionals who treat survivors of stressful and traumatic events; who treat peo- ple with mood, anxiety, and stress-related disorders; and who work in vocational settings with people with mental and physical disabilities. Stebnicki believes that monitoring our empathy fatigue is critical for maintaining our emotional, physi- cal, and spiritual well-being.

Linnerooth, Mrdjenovich, and Moore (2011) contend that human service pro- fessionals who experience and demonstrate empathy toward their clients are at greater risk for compassion fatigue, a condition that escalates when profession- als fail to recognize and attend to their own needs. They add, “paradoxically, the more empathic providers are toward their clients, the more likely they are to internalize their clients’ trauma” (p. 88). Skovholt (2012) suggests that counselors need “to learn to be both present and separate and also to be able to strategically attach, detach, and reattach” (p. 128). Skovholt and Trotter-Mathison (2016) write about empathy balance, which involves being able to enter the client’s world without getting lost in that world. Too little empathy results in the absence of caring, but too much empathy may result in practitioners losing themselves in the stories of their clients. The challenge is learning to balance caring for others with caring for self.

The work of professional counselors can lead to significantly increased levels of stress, which is often manifested in physical, mental, emotional, and spiritual fatigue. Clearly, the stress that clients experience and talk about in their therapy can have a major impact on therapists’ experience of stress, especially if they are not practicing self-care.

Other sources of stress are associated with working in managed care and educational systems. For mental health professionals who deal with managed care, pressures involve getting a client’s treatment approved, justifying needed treatment, quickly alleviating a client’s problem, dealing with paperwork, and the anxiety of being put in an ethical dilemma when clients are denied further clin- ically necessary treatment. For school counselors, in addition to the expectation that they can immediately solve the behavioral problems of children, there is the added stress of dealing with the frustrations of the family, the teachers, and the administrators in the school system. Although a multiplicity of demands are placed on school counselors, they often must function alone with little opportu- nity for their own supervision or for talking about how their work is affecting them personally.

This is equally true for clinicians in private practice who practice in iso- lation and do not have the benefits of working with colleagues. Therapists in private practice can connect with other colleagues in the field at regularly

cheduled consultations or supervision groups. Even if you work in an office with other therapists, you may not see them often because they are busy with clients, which leaves little time for interacting on a personal or professional basis. Therapists who work with violent and suicidal clients are particularly vulnerable to stress, and it is essential that they develop self-care strategies to avoid burnout. At times, demands may be placed on clinicians that are contrary to their training. Probation officers, the courts, and other stakeholders may view therapists treating sex offenders as an extension of the law enforcement team, creating particular expectations and some role ambiguity. A stressful work envi- ronment may not only lead to burnout among the staff but also have a negative impact on clients.

If you fail to recognize the sources of stress that are an inevitable part of help- ing, you will not have developed effective strategies to combat these stresses. You cannot expect to eliminate all the strains of daily life, but you can develop practi- cal strategies to recognize and cope with them. Doing so is a key part of being an ethical practitioner. Some professional organizations and state licensing boards have impaired professional or peer support programs. These programs can be a significant resource for dealing with the impacts of stress.

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Counselor Burnout and Impairment

Stress, distress, burnout, and vicarious traumatization are ongoing challenges associated with the work of helping professionals (Galek, Flannelly, Greene, & Kudler, 2011; Skovholt, 2012; Skovholt & Trotter-Mathison, 2016; Smith & Moss, 2009; Wise & Barnett, 2016). It is essential for therapists to practice self- care to protect their effective functioning and provide clients with the compe- tent services they deserve (Wise & Barnett, 2016). Clinicians who do not engage in self-care practices are at risk of not being able to competently fulfill their professional duties. Neglecting self-care “can undermine our confidence and hurt our ability to practice ethically. It can sink us in discouragement, com- passion fatigue, and burnout” (Pope & Vasquez, 2016, p. 114). Burnout is a state of physical, emotional, intellectual, and spiritual depletion characterized by feelings of helplessness and hopelessness. Maslach (2003) identifies burn- out as a type of job stress that results in a condition characterized by physi- cal and emotional exhaustion, depersonalization, and a reduction of personal accomplishments. Long work hours, seeing difficult clients, heavy involve- ment in administrative duties, and the perception of having little control over work activities can place practitioners at high risk for emotional exhaustion and depersonalization (Stevanovic & Rupert, 2009). Although some level of involvement with clients provides a sense of personal accomplishment, over- involvement requires extra time and depletes emotional energy, which puts clinicians at risk for experiencing the negative components of burnout (Rupert, Miller, & Dorociak, 2015).

In recent years Fried and Fisher (2016) have found that clinicians and researchers are calling attention to the negative consequences of prolonged

and extreme emotional stress among practitioners who work with vulnerable and at-risk populations. Professional work with people who are diagnosed with mental health conditions can be rewarding, yet it is highly stressful as well. In a study of the antecedents and consequences of burnout in psychotherapists, Lee, Lim, Yang, and Lee (2011) found that emotional exhaustion was most closely related to job stress and excessive involvement with clients. Vilardaga and his colleagues (2011) list some difficult conditions that lead to burnout among addic- tion and mental health counselors: funding cuts, restrictions on the delivery of services, changing certification and licensure standards, mandated clients, spe- cial needs clients, low salaries, staff turnover, agency upheaval, and limited career opportunities.

If practitioners do not take steps to remedy burnout or make changes in how they deal with stress, the eventual result is likely to be impairment. Impairment is the presence of a chronic illness or severe psychological depletion that can prevent a professional from being able to deliver effective services and often results in con- sistently functioning below acceptable practice standards. A number of factors can negatively influence a counselor’s effectiveness, both personally and profession- ally, including substance abuse, chronic physical illness, and burnout. Impaired professionals are unable to effectively cope with stressful events and are unable to adequately carry out their professional duties. Therapists whose inner conflicts are consistently activated by client material may respond by distancing themselves, which clients may interpret as a personal rejection.

In a survey of work–family conflict and burnout among practicing psy- chologists, Rupert, Stevanovic, and Hunley (2009) found evidence support- ing the interdependence of family- and work-life domains. Family support is related to well-being at work and to lower levels of burnout. Conflict between the work and family domains has a significant impact on how psychologists feel about their work. Rupert and colleagues (2009) contend that strategies to reduce burnout among psychologists must extend beyond the work setting to consider the quality of family life and the integration of work and family life. Rupert and colleagues (2015) report that minimizing conflict between the demands of work and family life is of central importance in reducing the risk of burnout. They note that the positive psychology movement focuses less on negative aspects of stress and more on building job engagement and positive attitudes toward work. This positive focus is a primary prevention approach that rests on internal and external resources. To prevent burnout, Rupert and colleagues “encourage taking a proactive approach and striving to maximize a fit between work demands and personal strengths, to develop resources at work and at home, and to establish a balance between work and personal lives” (pp. 172–173).

We ask you to reflect on the sources of stress in your life. What patterns do you see? How do you manage your stress? What steps are you taking to prevent burnout?

Do you ask peers, colleagues, or supervisors for help? • Are you willing to make time outside of your regular school or work hours to

seek supervision? • Do you seek personal therapy, body work (massage, yoga, Pilates), and spiri- tual practices when doing so might be beneficial?

Do you have a passion in your life other than your work? • Are you able to create space in your life for the things you value such as family,

friendships, and personal hobbies or interests?

Take action now to guard against burnout. Consider these strategies for self-care:

Schedule time for yourself. • Find a hobby that you can do regularly. • Make time to be with family and friends. • Consult with colleagues and seek peer support. • Avoid making your work the center of your life. • Maintain a balance between work and leisure. • Balance other-care with self-care.

To learn more about stress in the helping professions, preventing compassion fatigue and burnout, and self-care strategies, we recommend The Resilient Practi- tioner by Skovholt and Trotter-Mathison (2016).

EThiCs CodEs: Professional Impairment

American Association for Marriage and Family Therapy (2015)

Marriage and family therapists seek appropriate professional assistance for issues that may impair their work performance or clinical judgment. (3.3.)

National Organization for Human Services (2015)

human services professionals strive to develop and maintain healthy personal growth to ensure that they are capable of giving optimal services to clients. When they find that they are physically, emotionally, psychologically, or otherwise not able to offer such services they identify alternative services for clients. (standard 35.)

American Psychological Association (2010)

When psychologists become aware of personal problems that may interfere with their per- forming work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their work-related duties. (2.06.b.)

American Counseling Association (2014)

counselors monitor themselves for signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when impaired. they seek assistance for problems that reach the level of profes- sional impairment, and, if necessary, they limit, suspend, or terminate their professional responsibilities until it is determined that they may safely resume their work. counsel- ors assist colleagues or supervisors in recognizing their own professional impairment and provide consultation and assistance when warranted with colleagues or supervisors showing signs of impairment and intervene as appropriate to prevent imminent harm to clients. (c.2.g.)

c h 3 Values and the Helping Relationship

trainers) must develop the cognitive complexity and flexibility to hold their own personal beliefs in a way that allows them to be able to serve a diverse clientele in a beneficial, nonharmful manner” (p. 265). Sells and Hagedorn (2016) suggest that it is possible for students to integrate their personal values and religious identity with a new professional identity. This can be done by introducing a student who is struggling with a value conflict to a mentor who is a faculty member or a work- ing professional who shares common values with the student and who is able to integrate personal values with ethical practice. The mentor can demonstrate “to a student how he or she can embrace religious faith and professional ethical obligations simultaneously” (p. 271). Students also have some responsibility, in collaboration with faculty and supervisors, to find a suitable values mentor when they are struggling with a conflict between their personal and professional values (Brad Johnson, personal communication, August 14, 2016).

The religious values of some counselors are in conflict with the affirmation of diverse sexual orientations, and some counseling programs are in institutions that disaffirm or disallow diverse sexual orientations. Smith and Okech (2016a) asked: “How does CACREP simultaneously honor both religious diversity and sexual orientation diversity in its accrediting practices” (p. 252)? Smith and Okech (2016a) identified 15 CACREP-accredited programs in faith-based institutions that have anti-LGBT codes or disaffirming codes of conduct and doctrinal statements that are informed by a conservative Christian religious doctrine. Clearly, the mis- sion and policies of these institutions are in conflict with the ACA’s (2014) non- discrimination standard. Counseling students in such programs may feel justified in exposing their clients to their own personal religious beliefs regarding sexual morality and what kind of relationships are acceptable because those beliefs are espoused by their faculty and enshrined in institutional policy.

Smith and Okech (2016a) also identified 17 CACREP-accredited programs in faith-based institutions with LGBT-affirming codes or nondiscriminatory policies and codes of conduct. The differences between programs with disaffirming codes of conduct and programs that affirm sexual diversity demonstrates a need for increased dialogue in the counseling profession and a “call upon counselor educa- tors to develop empirically informed best practice to guide faculty who must nav- igate such discriminatory institutional norms” (p. 258). Smith and Okech (2016b) contend that “it is time for the field to provide clarification on the systemic issue of how to negotiate accreditation practices related to religious institutions that disaf- firm or disallow LGB-identified students and faculty” (p. 283). It should be noted that institutions that are not LGBT-affirming, regardless of the mission or policies of the institution, must abide by all CACREP standards.

Hancock (2014) asserts that it is the mission of education and training institu- tions to provide a context in which students can acquire the attitudes, knowledge, and skills essential for providing diversity-competent mental health services. Counselors’ personal beliefs and values must not supersede professional man- dates to serve the best interests of their clients. Phan, Hebert, and DeMitchell (2013) contend that the profession should define the responsibilities that must be met by all counselors: “A profession by its very nature requires its members to set aside their personal preferences to serve the needs and interests of the person receiving their service” (p. 62).

Clarifying Your Values and Their Role in Your Work

Counselors must develop the ability to manage their personal values so that they do not unduly influence the counseling process. Kocet and Herlihy (2014) describe this process as ethical bracketing: “intentional setting aside of the counselor’s personal values in order to provide ethical and appropriate coun- seling to all clients, especially those whose worldviews, values, belief systems, and decisions differ significantly from those of the counselor” (p. 182). Setting aside our personal values does not mean that we must give up or change our values (Kaplan et al., 2017). Counselors do not have to like or agree with their clients’ choices to fulfill their ethical obligation to help those seeking their assis- tance. Many clients will have a worldview different from that of the counselor, and clients bring to us a host of problems. They may have felt rejected by oth- ers or suffered from discrimination. Clients should not be exposed to further discrimination by counselors who refuse to render services to them because of differing values.

In our ethics courses, students sometimes ask, “Can I put a values statement in my informed consent document that communicates the nature of my personal values so prospective clients can make an informed decision about whether to enter a professional relationship with me?” If you were to incorporate a personal values statement in your informed consent materials, what would you include? Would you identify specific areas you have difficulty maintaining objectivity about because of the values you hold? Would you include your position on any of the value areas we address in this chapter? Although perhaps well intentioned, such disclosures put the emphasis in the wrong place—on the counselor’s values. This can easily convey a judgmental attitude to clients about issues with which they may be struggling. Clients often come to therapy in search of a safe and sup- portive environment in which they can share secrets and unburden themselves of shame or guilt. Clients are in a vulnerable position and need understanding and support from a counselor, not judgment.

In counseling, your clients struggle to make changes in their lives. We question the underlying assumption that counselors have greater wisdom than their clients and can prescribe better ways of being happier. Unquestionably, psychoeducation is a part of counseling, and counselors do facilitate a process of helping clients gain a fuller understanding of their problems. However, the process of counseling is meant to help clients discover their own resources for dealing with problems rather than listening to advice from others. Counseling is a dialogue between ther- apist and client that is meant to further the client’s goals and empower the client to make choices that are in his or her best interest.

The following questions may help you begin to think about the role your val- ues will play in your work with clients:

Do you think it is ever justified to influence a client’s set of values? If so, when and in what circumstances?
In what ways could discussing your values with clients unduly influence the decisions they are making?
Can you interact honestly with your clients without making value judgments?
If you were convinced that your client was making a self-destructive decision, would you express your concerns?
Do you think therapists are responsible for informing clients about a variety of value options?
How are you affected when your clients adopt your beliefs and values? • Are you able to allow your clients to select their own values and live by their

beliefs, even if they differ from yours? • Do you think a referral is ever justified on the basis of a conflict of values

between a counselor and client? If so, in what instances? • Do you believe certain values are inherent in the therapeutic process? If so,

what are these values? • How does exposing your clients to your viewpoint differ from subtly influenc-

ing them to accept your values? • What are some potential advantages and disadvantages in having similar life

experiences with your client? • In what ways are challenging clients to examine their values different from

imposing values on them?

Because your values can significantly affect your work with clients, you must clarify your assumptions, core beliefs, and values and the ways in which they may influence the therapeutic process. If counselors have a strong commitment to values they rarely question, whether these values are conventional or unconven- tional, may they be inclined to promote these values at the expense of their clients’ exploration of their own attitudes and beliefs? If counselors rarely reflect on their own values, it is unlikely that they can provide a climate in which clients can examine their values. Exploring values is at the heart of why many counselor edu- cation programs encourage personal therapy for counselors in training. Personal therapy sessions provide an opportunity to examine your beliefs and values and to explore your motivations for wanting to share or impose these beliefs. Clinical supervision sessions are another arena in which the impact of values when work- ing with clients can be examined. Ongoing clinical supervision throughout one’s professional career is also encouraged.

In the following sections we examine some sample cases and issues to help you clarify what you value and how this might influence the goals of counseling and the interventions you make with your clients. As you read these examples, keep the following questions in mind:

What is my position on this issue? • Where did I develop my views? • Am I open to being challenged by others? • Under what circumstances would I disclose my values to my clients? Why?

What are my reasons for wanting to reveal my values to a client? • Do my actions respect the principle of clients’ self-determination that is con-

sistent with their culture

The Ethics of Imposing Your Values on Clients

The imposition of values by the counselor is an ethical issue in counseling individ- uals, couples, families, and groups. Value imposition refers to counselors directly attempting to influence a client to adopt their values, attitudes, beliefs, and behav- iors. It is possible for mental health practitioners to do this either actively or pas- sively, and with or without awareness. Jadaszewski (2016) contends that mental health practitioners and consumers of psychotherapy services often lack aware- ness of the role values play in the psychotherapeutic endeavor. At times, therapists may unintentionally influence clients to change some of their values and behaviors in certain directions. Jadaszewski suggests that a key aspect of informed consent is clarifying with clients some potential ways that values can influence psycho- therapy. Informing clients about the role of values in therapy can guard against undue influence by the therapist. For example, a key element in some addiction treatment programs is that clients accept that there is a power higher than them- selves. Although clients are encouraged to define for themselves what this higher power is, some addiction counselors may be tempted to impose their own per- sonal beliefs of what the higher power is, which raises ethical issues. Counselors are cautioned about this kind of value imposition in their professional work in this ACA (2014) standard:

Counselors are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors. Counselors respect the diversity of clients, trainees, and research par- ticipants, and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature. (A.4.b.)

School counselors receive a similar caution in the ASCA (2016) code:

[School counselors] respect students’ and families’ values, beliefs, sexual orientation, gender identification/expressions and cultural background and exercise great care to avoid imposing personal beliefs or values rooted in one’s religion, culture or ethnicity. (A.1.f.)

A school counselor violated these ethical standards and imposed her personal beliefs for a preference of sexual abstinence at her school. A South Shore Public School District counselor, Grossman claimed she was following her fundamental Christian beliefs when she removed the pamphlets on instruction in the use of condoms and replaced them with literature advocating abstinence. When her con- tract was not renewed, she brought suit against the school district, contending that the district was hostile to her religious beliefs (Grossman v. South Shore Public School District, 2007). The Seventh Circuit Court of Appeals took the position that reli- gious beliefs do not trump the policies and requirements of the employing school district. Grossman acted unethically in disregarding the curriculum of the school and advocating her own personal beliefs about abstinence. The court concluded that the nonrenewal of her contract was based on her actions rather than on her personal beliefs (Phan et al., 2013).

In group work, values imposition may come from both the leader and the members in the group. The group leader should not short-circuit members’ exploration of issues by providing answers. Some members may inappropriately respond by giving advice to another member. Value clashes often occur between members, and leaders have a responsibility to intervene so that no member can impose his or her values on others in the group. The group leader’s central func- tion is to help members find answers that are congruent with their own values, and these answers will not be the same for all group members.

Value Conflicts: To Refer or Not to Refer

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David Kaplan, chief professional officer at the American Counseling Association, states that the lack of competence across sexual orientations cannot be used as an excuse to refuse to counsel an LGBT client (personal communication, August 6, 2016). All counselors are expected to have basic competencies across race, ethnic- ity, gender, sexual orientation, and all other characteristics listed in the nondis- crimination statement of the ACA’s (2014) Code of Ethics. Farnsworth and Callahan (2013) state that values are intrinsic to the process of psychotherapy, and value conflicts will occasionally pose challenges for conducting therapy, regardless of how accepting and compassionate the trainee may be.

Merely disagreeing with a client’s value system is not ethical grounds for a referral; it is possible to work through value conflicts successfully. Consider a referral only when you clearly lack the necessary skills to deal with the issues presented by the client. Do not try to convince yourself that you are working in a client’s best interest by referring a person because of your discomfort with their beliefs and actions. Farnsworth and Callahan (2013) believe referrals are appro- priate when they reflect self-awareness on the part of the trainee that the client’s goal is beyond the scope of the trainee’s competence. Farnsworth and Callahan (2013) suggest that trainees who experience discomfort with certain clients should honestly consider the degree to which prejudice may be biasing their evaluation of a situation. “Because value conflicts are an inescapable element of psychother- apy, the best protection that can be afforded to clients is for all trainee clinicians to develop greater personal and professional awareness of their own values and rec- ognize the impact that those values have on the services they provide” (p. 205). To competently deal with value conflicts, trainees must maintain awareness of poten- tial conflict areas with clients and their own internal reactions to clients through- out the duration of the therapy process. The counseling process is not about your personal values; it is about the values and needs of your clients. Your task is to help clients explore and clarify their beliefs and apply their values to solving their problems. If clients conclude that their lives are not fulfilled, they can use the counseling relationship to reexamine and modify their values or their actions, and they can explore the range of options open to them.

Hancock (2014) provides a core principle in managing value conflicts: “When there is a conflict between a student’s ‘sincerely held’ religious beliefs and the needs of that client, without question the client’s needs must come first” (p. 6). Referring a client because his or her religious beliefs conflict with your values can and does lead to feelings of abandonment and violates the ethical principle of

do no harm” (David Kaplan, personal communication, August 6, 2016). Before considering a referral, explore your part of the difficulty through consultation or supervision. What barriers within you would make it difficult for you to work with a client who has a different value system? When you recognize instances of such value conflicts, ask yourself these questions: “Who’s comfort is paramount in the client–counselor relationship?” “Why is it necessary that there be congruence between my value system and my client’s value system?” “Have I considered the potential for harm to my client in making a referral?”

It can be burdensome for clients to be saddled with your disclosure of not being able to get beyond value differences. Clients may interpret this as a personal rejection and suffer harm as a result. Counseling is about working with clients within the framework of their value system. If you experience difficulties over conflicting personal values, the ethical course of action is to seek supervision and learn ways to effectively manage these differences. Linde (2016) points out that the 2014 ACA Code of Ethics makes it clear that counseling is about the client, not the counselor.

Value conflicts may become apparent only after a client has been working with you for some time. Consider this scenario. You believe you would have difficulty counseling a woman who is considering an abortion. You have been counseling a woman for several months on other concerns, and one day she discloses that she is pregnant. She wants to explore all of her options because she is uncertain about what to do. Would you tell your client that you needed to refer her because of your values pertaining to abortion? Could such a referral be considered client abandonment? Would it be ethical for you to offer advice from your value position if she asks for your advice? What are the ethical and legal aspects of imposing your values on this client? If you cannot maintain objectivity regarding a certain value, this is your dilemma to struggle with and is not the client’s problem. Your ethical responsibility is to seek supervision or consultation. If you were to refer this client, you still have the obligation to understand how this conflict of values may be influencing the direction of therapy and why you considered a referral to be necessary (Farnsworth & Callahan, 2013).

Discriminatory Referrals

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Many people think the mandate to avoid discriminatory referrals is a new direc- tive. However, this mandate is consistent with Carl Rogers’s concept of uncon- ditional positive regard, which has influenced the counseling profession for more than 50 years. Person-centered theory rests on the foundation of acceptance, respect for a client’s autonomy, and avoidance of judgment. These core principles are infused in the ACA’s Code of Ethics (David Kaplan, personal communication, August 6, 2016).

It is understandable that students often wrestle with the question of when to refer a client. Professional associations do not present a uniform theme, and different professions have different positions on the justification for referral due to a clinician–client value conflict. If ethics scholars and professional associations have differing perspectives, counselor education faculty and students also may be unclear about the circumstances determining the ethics of referrals.

Insufficient training is sometimes used as an excuse or a cover for the real reason for making a referral—the counselor’s difficulty with the client’s values. Beginning counselors often have not had enough time or experience to feel com- petent across a wide range of client problems. When faced with a topic you know little about, good first steps are to educate yourself, seek supervision, and obtain further training. It may seem that you are only one step ahead of your client in terms of knowing how to help this person, but the impulse to refer can hurt the client. It also will significantly inhibit your growth as an effective counselor.

Shiles (2009) notes that far too little has been written about situations in which referring a client is inappropriate, unethical, and may constitute an act of discrim- ination. Shiles asserts that inappropriate referrals have been made for clients with differing religious beliefs, sexual orientations, or cultural backgrounds. Counsel- ors often rationalize these referrals as a way to provide the client with the best services; however, such practices may ultimately be discriminatory. Shiles makes the following observations:

Referrals have become common practice among mental health service pro- viders at the expense of exploring other possibilities. Mental health providers may not be aware of the potential ethical violation in their referral decision because this topic is not highlighted in the professional literature.
The overuse of client referral among mental health providers often involves discriminatory practices that are rationalized as ways to avoid harming the cli- ent and practicing beyond one’s level of competence. Discriminatory referrals have gone unnoticed and unchallenged far too often.
The psychological community needs to critically examine why mental health practitioners may refer clients over value conflicts and why these practitioners assume that such practices are appropriate, reasonable, and acceptable.

The Code of Ethics of the American Association for Marriage and Family Ther- apy (2015) has this nondiscrimination standard: “Marriage and family therapists provide professional assistance to persons without discrimination on the basis of race, age, ethnicity, socioeconomic status, disability, gender, health status, reli- gion, national origin, sexual orientation, gender identity or relationship status” (1.1). The AAMFT code also addresses referrals: “Marriage and family therapists respectfully assist persons in obtaining appropriate therapeutic services if the therapist is unable or unwilling to provide professional help” (1.10). We have dif- ficulty with the concept of a therapist being unable or unwilling to work with a client. This vague wording can be used to discriminate and seems to open the door to referral based primarily on a therapist’s values or personal beliefs and preferences. What does unable mean? What are the implications of being unwilling? These two AAMFT standards seem to contradict each other, and clarification is sorely needed.

McGeorge, Carlson, and Farrell (2016) studied family therapists’ beliefs and practices related to the referral of lesbian, gay, and bisexual clients and found that the majority of participants believed it is ethical to refer LGB clients based on coun- selors’ (a) values and religious beliefs, (b) negative beliefs about LGB people and relationships, and (c) lack of competence in working with LGB individuals. This result surprised McGeorge and her colleagues because the preponderance of the

iterature concludes that referral based on sexual orientation is a discriminatory practice that harms LGB individuals. They take the position that “training pro- grams need to communicate that students are expected to develop clinical compe- tence to work with LGB clients, which teaches students that they cannot ethically make the choice to avoid working with this or any other population” (p. 15).

We tell our students who want to make a referral based on a value conflict to ask themselves these questions:

What skills am I lacking in counseling a client struggling with a critical life decision?
Is this my issue and feelings of discomfort or are these my client’s feelings? • Can I obtain the knowledge necessary to acquire competence through contin-

uing education, consultation, or supervision? • How quickly can I gain the knowledge necessary to be of service to my client? • What is stopping me from gaining that knowledge, supervision, or

consultation? • How can I determine what would ethically justify a referral?

A related key question is, “When does an individual become a client?” Kaplan’s (2014) answer is that “the counselor’s ethical obligations to an individual start at first contact or assignment, not at the first session” (p. 146). For example, a coun- selor in private practice who does not have any openings cannot dismiss a per- son who calls inquiring about services. The counselor has an ethical obligation to provide alternative options, such as other practitioners in the area. This ethical obligation is present even though the counselor will never provide any counseling services to the individual.

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The Legal Framework Regarding Values Discrimination

Counselors are sometimes too eager to suggest a referral rather than explore how they could work with a client’s problem. In two recent court cases, Christian stu- dents filed suit against their public universities over the requirement that students avoid imposing their moral values on clients.

Julea Ward was enrolled in a counseling program at Eastern Michigan Univer- sity. She frequently expressed a conviction that her Christian faith prevented her from affirming a client’s same-sex relationship or a client’s heterosexual extramar- ital relationship. During the last phase of her program in 2009, Ward was enrolled in a practicum that involved counseling clients and was randomly assigned to counsel a gay client. Ward asked her faculty supervisor either to refer the client to another student or to allow her to begin counseling and make a referral if the counseling sessions involved discussion of his relationship issues.

Ward was told that refusing to see a client on the basis of sexual orientation was a violation of the ethics code for the counseling profession and was there- fore not acceptable. The counseling program initiated an informal and then a for- mal review process into Ward’s request for a referral. The program offered her a

plan for remediation, which she refused. Ward was dismissed from the program because of her refusal to counsel gay clients and her unwillingness to participate in a remediation plan that would help her manage her personal values in such a way as to avoid imposing her beliefs and values on clients.

Ward sued the university in U.S. District Court, claiming that her dismissal vio- lated her religious freedom and her civil rights. The district court ruled that the uni- versity was justified in dismissing Ward for violating provisions of the code of ethics that prohibit discrimination based on race, religion, national origin, age, sexual ori- entation, gender, gender identity, disability, marital status/partnership, language preference, or socioeconomic status. The court also ruled that the university was jus- tified in enforcing a legitimate curricular requirement, specifically that counseling students must learn to work with diverse clients in ways that are nondiscriminatory.

The Alliance Defending Freedom (ADF) is a legal organization that defends individuals and organizations whose conservative religious views or actions are challenged in various arenas of public life. It was founded and funded in 1994 by several key evangelical Christian leaders and has since taken on many conserva- tive religious causes (Perry Francis, personal communication, September 25, 2016). With help from the ADF, Ward appealed her case to the United States Court of Appeals for the Sixth Circuit, which sent the case back to district court for a jury trial. To avoid a costly trial, the case was settled out of court. As part of the settle- ment, the ADF dropped their demands that the university’s curriculum, policies, and practices be changed (Eastern Michigan University, 2012).

A second related court case had a similar outcome. Jennifer Keeton, enrolled in a counseling program at Augusta State University, actively sought to impose her religious and moral values on clients whose behavior she deemed to be morally wrong. Keeton stated that her intention was to recommend “conversion therapy” to gay clients and to inform them that they could choose to be straight. She was dismissed from the program when she declined to participate in a remedial pro- gram designed to assist her in managing to keep her personal values separate from those of a client. The federal appeals court upheld the right of the university to enforce standards expected of students in a counseling program, even when a student objects on religious grounds. Keeton asked the court to order her reinstate- ment in the program, but the court dismissed her case, stating that the university was justified in enforcing ethical standards for its students (Rudow, 2012).

Some key lessons can be learned from analyzing the Ward and Keeton cases. The courts recognized the right of university programs to adopt policies that prohibit discrimination based on a professional association’s code of ethics. The courts agreed that training programs can prohibit students from imposing their values on clients (Behnke, 2012). Counselor education programs have an ethical responsibility and a legal right to ensure the appropriate treatment of clients who are under the care of their supervisees (Julie Whisenhunt, personal communication, October 5, 2016).

State Legislation to Protect Religious Freedom

In some states “freedom of conscience” clauses are being inserted into legisla- tion in an attempt to protect religious freedom. For example, Arizona’s Senate Bill 1365 ensures that mental health professionals will not put their licensure

status in jeopardy by denying services to clients on the basis of sincerely held religious beliefs. This bill was signed into law by the governor of Arizona in May 2012.

The state of Tennessee passed controversial legislation in 2016 that would allow therapists in that state with “sincerely held principles” to deny services to potential clients who identify as lesbian, gay, bisexual, or transgender without risk of legal consequences. This discriminatory bill under the guise of “religious freedom” seeks to protect conservative therapists from certain 2014 changes in the American Counseling Association’s Code of Ethics. As long as reluctant prac- titioners refer the client to another qualified professional, the bill states that they will be protected from licensure suspensions and any legal penalties. Supporters claim the bill protects the rights of therapists by allowing them to refer individ- uals to more appropriate professionals. Opponents claim that this legislation is part of a wave of bills around the country that legalizes discrimination against lesbian, gay, bisexual, and transgender people. The American Counseling Associ- ation’s CEO, Richard Yep (2016), contends that denying services based on a coun- selor’s personal beliefs could harm access to professional care for many of the most vulnerable individuals. We agree with Yep’s position: “These so-called ‘reli- gious freedom’ bills set a dangerous precedent and send a harmful message that fairness and equality are secondary to personal opinion” (p. 7). Meyers (2016a) writes that discriminatory attitudes and policies seem to be on the increase since the Supreme Court’s decision in June 2015 requiring states to recognize the valid- ity of same-sex marriages. “Currently, there are nearly 200 pieces of proposed anti-LGBT legislation in the United States” (p. 25). Wise and her colleagues (2015) believe that these legislative initiatives (such as the bills enacted in Arizona and Tennessee) limit the ability of educators to train students to provide competent care to a diverse public. Such legislative actions are potentially in conflict with the ethical commitment to nondiscrimination outlined in the ethical standards for the APA and the ACA.

We find it disconcerting that in some states students and practitioners in the helping professions are being given the legal right to refuse to offer counseling ser- vices to a client who does not share their religious beliefs and moral convictions. Mental health professionals should be able to work effectively with the diversity of worldviews, beliefs, and cultural identities they will encounter; conscientious objection acts clearly violate the letter and spirit of the ethics codes of the help- ing professions. If counseling students are not willing to learn to work with the wide range of clients they will encounter, we suggest that they reconsider whether counseling is the right profession for them.

Informed Consent on Managing Personal Values

Prior to enrollment, prospective students must be informed about what is expected of them as ethical practitioners, especially their ethical responsibilities when work- ing with clients who have diverse value systems. Counselor education programs have a responsibility to clearly and comprehensively inform incoming students about the ethical aspects of managing their values and what is expected of them as ethical practitioners. Bieschke and Mintz (2012) have proposed that training

programs use a Values Statement to inform prospective students about the com- petencies they will be expected to develop during their training program.

The Values Statement offers a path in which trainees can simultaneously maintain their values and offer competent care to diverse others. The Values Statement does this by outlining the competencies expected of trainees in regard to working with clients whose worldviews differ markedly from their own. (p. 198)

It is recommended that this statement appear on the program’s website as well as in the student handbook, and that students be required to sign and date their acknowledgment that they have read and understood the statement.

Students have a right to maintain their personal values; they are not asked to change those values and beliefs. However, they have an ethical responsibility to acquire and use professional knowledge and skills in serving the diverse range of clients that they are likely to encounter in their practice. Personal values and professional values and skills can coexist even when they are in tension (Pipes, Holstein, & Aguirre, 2005).

Prior to admission students should be told that they cannot ethically discrim- inate against clients because of a difference in values or refuse to work with a general category of clients. In light of the contentious court cases and legislative actions, Wise and her colleagues (2015) call for training programs to take a pro- active approach to conscience clauses rather than assume a reactive stance. They recommend that students who are entering a program indicate explicit agreement with nondiscrimination policies. According to Bieschke and Mintz (2012), use of a Values Statement helps training programs prevent future legal and legislative battles. When potential counseling students are informed of the expectations of the program early in the admissions process, they have time to decided whether they want to enroll in the program. Students need to be aware of the fundamen- tal aspects of the code of ethics because these requirements will influence their development as mental health professionals and will affect their participation in the program.

Seeking Supervision Regarding Your Values

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We have emphasized that it is not ethical to refer clients based solely on a differ- ence of values and beliefs between the counselor and the client. Through super- vision, counselors in training can learn how to manage their values and how to avoid using their professional role to influence clients in a given direction or to make decisions for clients about how to live. In addition, counselors in training can explore their values and beliefs and increase their self-awareness and iden- tify potential future or current value discrepancies in personal therapy. By being proactive, counselors in training can guard against unintentionally imposing their values on clients. It is the professional responsibility of the counselor to be invested in the process of a client’s decision making rather than directing the person toward outcomes that the counselor deems “right.” When counselors enter a professional relationship, they take on the values of the profession as expressed in the code of ethics and are expected to bracket off personal values as they enter the world of the client (Sells & Hagedorn, 2016).

Can you counsel people who are experiencing conflict over their sexual choices if their values differ dramatically from your own? If you have liberal attitudes about sexual behavior, will you be able to respect the conservative views of some of your clients? If you think their moral views are giving them difficulty, will you try to persuade your clients to adopt a more liberal view? How will you deal with the guilt clients may experience? Will you treat it as an undesirable emotion that they need to overcome? Conversely, if you have strict sexual guidelines for your own life, will the more permissive attitudes of some of your clients be a problem for you? Who has influenced your choices pertain- ing to sexual practices? In general, how comfortable would you be discussing sexual practices and concerns with your clients? How willing or able are you to talk about sexual practices with clients whose sexual orientation is different from your own? Ignoring talk of sexuality with clients can lead to unintended harm and negative outcomes. In our experience, both counselors in training and licensed professionals may experience personal discomfort and lack professional competence when talking about issues of sexuality with clients. Harris and Hays (2008) found that “therapists’ perceived sexual knowledge, and their comfort with sexual material, influenced their willingness to engage in sexuality-related discussions with their clients” (p. 239). We find that the more experience stu- dents have in talking openly about sexuality in their training and supervision, the greater the likelihood that they will raise relevant issues of sexuality with their clients.

Consider the following case as a way to clarify how your values would influ- ence your interventions with this couple.

The Case of Lee and Juan

During the past few years Lee and juan have experienced many conflicts in their relationship. although they have made attempts to resolve their problems by themselves, they have finally decided to seek the help of a counselor. even though they have been thinking about separat- ing with increasing frequency, they still have some hope that they can achieve a satisfactory relationship.

three couples counselors, each holding a different set of values pertaining to intimate rela- tionships, describe their approach to working with Lee and juan. as you read these responses,

hink about the degree to which each represents what you might say and do if you were coun- seling this same-sex couple.

Counselor A. this counselor believes it is not her place to bring her values pertaining to the relationship into the sessions. she is fully aware of her biases regarding the preservation of long-term relationships, and she does not impose nor expose these val- ues. Her primary interest is to help Lee and juan discover what is best for them as indi- viduals and in their relationship. she sees it as unethical to push her clients toward a definite course of action, and she lets them know that her job is to help them be honest with themselves.

What are your reactions to this counselor’s approach? • What values of yours could interfere with your work with Lee and juan?

Counselor B. this counselor has been married three times herself. she maintains that far too many couples stay in their marriages or long-term relationships and suffer unnecessarily. she explores with Lee and juan the conflicts that they bring to the sessions. the counselor’s interventions are leading them in the direction of separation as the desired course of action, especially after they express this as an option. she suggests a trial separation and states her willingness to counsel them individually, with some joint sessions. When Lee brings up his guilt and reluctance to separate because of the commitment they made to each other, the counselor confronts him with negative consequences to each of them by staying in an unsatisfactory relationship.

What, if any, ethical issues do you see in this counselor’s work? is this counselor exposing or imposing her values?
What interventions made by the counselor do you agree with? What are your areas of disagreement?

Counselor C. at the first session this counselor states his belief in the preservation of long-term relationships. He believes that many couples give up too soon in the face of difficulty. He says that most couples have unrealistically high expectations of what constitutes a “healthy relationship.” the counselor lets it be known that his expe- rience continues to teach him that separation rarely solves any problems but instead creates new problems that are often worse. He tells the couple of his bias toward sav- ing their relationship so they can make an informed choice about initiating counseling with him.

What are your personal reactions toward the orientation of this counselor?
Do you agree with him stating his bias?
if he kept his bias and values hidden and accepted this couple into therapy, do you think he could work objectively with them? Why or why not?

Commentary. this case shows how the value system of the counselor can determine the direction of counseling. the counselor’s attitudes come into play in working with Lee and juan. the counselor who is dedicated to preserving a committed relationship is bound to func- tion differently from the counselor who puts primary value on the welfare of the individual. What might be best for one person in this relationship is not necessarily in their best interests as a couple. it is essential, therefore, for counselors who work with couples to be aware of how their values influence the goals and procedures of therapy. counselors b and c let their

values control the process of therapy. it is not the counselor’s responsibility to decide about the quality of the relationship or whether the relationship is worth saving. in ethical practice, clients are encouraged to look at their own values and to choose a course of action that is best for them. •

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Value Conflicts Pertaining to Abortion

People’s views about abortion are emotionally charged, and counselors may expe- rience a value clash with their clients on this issue. Clients who are exploring abor- tion as an option often present a challenge to clinicians, both legally and ethically. From a legal perspective, mental health professionals are expected to exercise “rea- sonable care,” and if they fail to do so, clients can take legal action against them for negligence.

Counselors are clearly obligated to familiarize themselves with the legal require- ments in their state that relate to abortion, especially if they are counseling minors considering an abortion. Laws, regulations, and policies vary widely; consult with an attorney when necessary. The matter of parental consent in working with minors varies from state to state. For example, in 1987 Alabama enacted the Parental Con- sent for Abortion Law, requiring physicians to have parental consent or a court waiver before performing an abortion on an unemancipated woman. Consider the situation of a young woman under the age of 18 who tells her school counselor that she is planning to get an abortion and does not want her parents to know about this. In Alabama this counselor is expected to explain this law to the young woman (including the option of a court waiver of parental consent) and advise her that the counselor is obliged to comply with this law, and not encourage any violation of it.

In the following vignette, we present the case of Brooke. What value conflicts, if any, might you face with Brooke? What issues do you find most challenging, and how might you deal with them? Review the eight steps in making an ethical decision outlined in Chapter 1. What steps would you take in dealing with this case in an ethical manner?

The Case of Brooke

brooke is a 14-year-old student sent to you because of her problematic behavior in the class- room. Her parents have recently separated, and brooke is having difficulty coping with the breakup. eventually, she tells you that she is having sexual relations with her boyfriend without using any form of birth control.

What are your reactions to brooke’s sexual activity?
What would you want to know about her boyfriend?
if you sense that her behavior is an attempt to overcome her feelings of isolation, how would you deal with it?
Would you try to persuade her to use birth control and practice safer sex? Why or why not? if you did, would this constitute an imposition of your values?

you have been working with brooke for several sessions now, and she discovers that she is pregnant. Her boyfriend is 15 and declares that he is in no position to support her and a child.

as you examine your own values pertaining to abortion as they may apply to the practice of counseling, reflect on these questions:

What would you do if you find it difficult to be objective due to your personal views on abortion?
if you were to consider referring brooke, how might she be affected by this action?
if you chose to refer brooke, what would your reasons be for doing so?
Other than a referral, what could you do outside of your counseling sessions with brooke to work through your own value conflict with her?
if you are firmly opposed to abortion, how could you bracket off your personal values and work within the framework of brooke’s values?
Which of your values are triggered by brooke’s case, and how could these values either help or hinder you in working with her?

are facing choices around unplanned pregnancy, it can be useful to ask them to talk about the value systems they hold and in what ways these values support or conflict with the choices they are considering. in situations such as this that are often highly value laden, it is crucial for the counselor to help the client explore his or her options while being sure to use the client’s frame of reference for the discussion.

if you determine that you could not work effectively with brooke, explore your reasons for making this decision with a supervisor, but not necessarily with the client. We would not want to burden brooke with our struggle pertaining to our values. We would seek consultation as a way of learning how to manage our personal values so that they would not have a negative impact when working with brooke. •

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Case Study of Other Possible Value Conflicts

In this section we present a case study that highlights value conflicts. Try to imag- ine yourself working with Reggie. How do you think your values would affect your work with him?

The Case of Reggie

reggie comes to see savannah, who has been a practicing therapist for 2 years. reggie is in a long-term relationship and he has had several affairs, which he blames mostly on his partner. His goal in therapy is to find some way to ameliorate his guilt. after a few sessions, savannah suggests he consider couples therapy because much of the content of his sessions has had to do with his relationship with his partner. He refuses this referral. she then tells him that she cannot, in good conscience, continue to see him because his behavior bothers her and she sees no way to help him obtain his goal of alleviating his guilt and continuing his affairs. savannah suggests that he seek another therapist and offers him three referrals.

What is your reaction to savannah’s refusal to continue counseling reggie?
is this a case of a therapist exposing or imposing her values on a client?
reggie’s goals for counseling are different from savannah’s goals for reggie. should she discuss this conflict with reggie, and if so, how?
What are the ethical considerations in this case? • How would you deal with reggie if he were your client?

Commentary. savannah is not being therapeutic by imposing her value system pertaining to affairs on reggie. this issue is not about her but about her client. On the other hand, reggie creates an impossible situation for himself by blaming his partner for his affairs and being unwilling to do couples therapy. it is the counselor’s job to explore the meaning of the client’s behaviors rather than rendering judgment. savannah can point out the ways in which reggie’s choices appear to be creating difficulties for him without treating him as though he is a “bad” person. Depending on how savannah handles termination and refer- ral, her client may feel that she has abandoned him. reggie seems more than willing to talk about his relationship, and this discussion may eventually lead toward a recommendation for couples counseling. •

Striving for Openness in Discussing Values

Beginning counselors may experience discomfort in working with clients for a variety of reasons. Their task is to learn to address this discomfort and see what it may be about. When you experience discomfort due to a client’s very different sys- tem of values, challenge yourself to develop ways of working with this client. Ask yourself why a client’s different values cause you discomfort and are problematic for you. Try to work collaboratively to identify and clarify the client’s value system and to determine the degree to which the client is living in accordance with his or her core beliefs and values. Your task is to discover what is problematic for the client and to explore this with the client. The emphasis should be on the client’s problem, and not on your problem with a client.

If you feel secure in your own values, you will not be threatened by really lis- tening to, and deeply understanding, people who think differently or people who do not share your worldview. Listen to your clients with the intent of understand- ing what their values are, how they arrived at them, and the meaning these values have for them. Being open to your clients can significantly broaden you as a per- son, and it will enhance your ability to work ethically and effectively with clients.

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The Role of Spiritual and Religious Values in Counseling

Addressing spiritual and religious values in the practice of counseling encom- passes particularly sensitive, controversial, and complex concerns. As you read the following section, clarify your spiritual or religious values and think about how your views might either enhance or interfere with your ability to establish meaningful contact with certain clients. It is important to be aware of and under- stand your own spiritual or religious attitudes, beliefs, values, and experiences if you hope to facilitate an exploration of these matters with clients. “Spirituality is often defined as a more personal quest for transcendence and meaning, [whereas] religion is often linked with dogma and ritual” (Barnett & Johnson, 2011, p. 148). We concur with Barnett and Johnson’s view that these constructs are related, and we use the terms interchangeably.

In our early years of practicing, the role of spirituality and religion in counsel- ing was not considered an appropriate topic for discussion. A shift has occurred over time, and today there is a growing awareness and willingness to explore spir- itual and religious beliefs and values within the context of the practice of coun- seling and counselor education programs (Barnett & Johnson, 2011; Dobmeier & Reiner, 2012; Hagedorn & Moorhead, 2011; Johnson, 2013). The topic of integrating spirituality and religion into the practice of counseling and psychotherapy has received increasing attention in the literature since the 1970s. Survey data of both practicing counselors and counselor educators indicate that spiritual and religious matters are therapeutically relevant, ethically appropriate, and potentially signifi- cant topics for the practice of counseling in secular settings (Delaney, Miller, & Bisono, 2007; Dobmeier & Reiner, 2012; Francis, 2016; Walker, Gorsuch, & Tan, 2004; Young, Wiggins-Frame, & Cashwell, 2007). However, controversy remains

over how to address and use spiritual and religious interventions and the ethical implications of such interventions in therapeutic practice (Francis, 2016). Smith and Okech (2016a) state that the ACA and CACREP should continue to acknowl- edge the role of spirituality and religion in counseling and point out that the ACA has endorsed the Association for Spiritual, Ethical, and Religious Values in Coun- seling’s (2009) Competencies for Addressing Spiritual and Religious Issues in Counsel- ing. We encourage you to review these competencies.

Worthington (2011) believes the increased openness of therapists to clients’ spiritual and religious concerns has been fueled by the multicultural movement. People have been empowered to define themselves from a cultural perspective, which includes their spiritual, religious, and ethnic values. Spirituality and reli- gion exist in all cultures. If therapists are to include spirituality in therapy, they must be comfortable with spiritual concerns as a topic of discussion in therapy. Johnson (2013) views spiritually informed therapy as a form of multicultural therapy. When the client is interested in talking about these matters, the first step is for the therapist to be sincerely interested in the client’s spiritual beliefs and experiences and how he or she finds meaning in life. Johnson believes that a client-defined and life-affirming sense of spirituality can be a significant avenue for connecting with the client and can be an ally in the therapeutic change process. However, the emphasis is on what the client wants, not on the therapist’s spiritual experiences or agenda for the client.

In the course of counseling, practitioners ask many questions about a client’s life, yet they sometimes omit inquiring about what gives meaning to a client’s life and what beliefs have provided support for the client in difficult times. Spiritual assessment provides insight into how a client relates to spirituality and religion and how this may be affecting the client (Dailey, 2012). Asking questions about a client’s religious or spiritual background at the outset of the professional rela- tionship conveys their potential relevance to the therapeutic process (Barnett & Johnson, 2011). If counselors do not include questions about a client’s spiritual or religious values and concerns during assessment, the client may be hesitant to bring up these concerns in their treatment.

For many clients, spirituality or religion are core aspects of their sense of self, worldview, and value system. Religious or spiritual concerns may be relevant to the motivation of some clients who seek therapy, either as areas of conflict for them or as sources of strength and support that can enhance the therapy process (Barnett & Johnson, 2011). Francis (2016) claims that clients’ core beliefs and values are often used as ways of coping and gaining support in times of challenge. “These beliefs and values are part of what makes up the cultural picture of the client and can be used by the skillful and sensitive counselor to help the client navigate the counseling process toward healing and wholeness” (p. 563). Meditation, prayer, being in nature, mindfulness, connecting with others, enjoying the arts, and yoga are some ways spirituality is used as a resource. The key is to find out what works for the client (Johnson, 2013). Some clients do not talk explicitly about spirituality but existential themes tend to emerge in therapy. Listen for how clients talk about their concerns regarding meaning, values, mortality, and being in the world. It is important to attend to how clients define, experience, and access whatever helps them stay connected to their core values and their inner wisdom.

Spiritual and Religious Values in Assessment and Treatment

Assessment is a process of looking at all the potential influences on a client’s prob- lem to form a holistic picture of the client’s current level of functioning. The explo- ration of spirituality or religious influences can be just as significant as exploring family-of-origin influences. During the intake and assessment process, the coun- selor will gather information on many aspects of a client’s life. Practitioners should remain finely tuned to their clients’ stories and to the reasons clients seek profes- sional assistance.

Frame (2003) presents many reasons for conducting assessments in the area of spirituality in counseling, some of which include understanding the worldview and the contexts in which clients live; assisting clients in grappling with questions regarding the purpose of living and what they most value; exploring religion and spirituality as client resources; uncovering religious and spiritual problems; and determining appropriate interventions. Assessment gives a counselor an oppor- tunity to identify possible influences that spirituality or religion may have on a client’s presenting problem. Francis (2016) points out that “if it is determined that a client’s religious or spiritual issues are having an impact on the creation, main- tenance, or resolution of his or her problems, a more comprehensive assessment of that interaction needs to be undertaken” (pp. 561–562). Based on the results of a comprehensive assessment, a determination can be made about the appropri- ateness of incorporating the client’s religious and spiritual beliefs and practices as part of the therapeutic process.

When clients indicate they are concerned about any of their religious beliefs or spiritual concerns or practices, the therapist needs to be capable of working at this level. However, counselors must be mindful of how this topic is introduced into the therapy process. It is not appropriate to urge clients to explore religion and spirituality if they do not see these as relevant factors in their lives. Therapists can unduly influence clients by bringing up matters of religion and spirituality when clients have indicated they are not interested in exploring these issues. Barnett and Johnson (2011) caution that “practitioners must avoid making religion a preemi- nent focus when it is not a significant concern for the client” (p. 153). For a more detailed discussion on spiritual assessment, see Cashwell and Young (2011b).

Ethical and Clinical Considerations With Nonreligious Clients

We also must honor the beliefs and concerns of individuals who identify as non- religious. Sahker (2016) focuses on ethical and clinical considerations in providing therapy with people who are nonreligious and estimates that between 16% and 23% of American adults and 33% of adults under the age of 30 claim to be non- religous. Individuals experiencing spiritual struggles may seek therapy when deciding to leave the religion of their family of origin. These clients may be seeking a safe place to discuss their doubts and distress related to internal conflicts involv- ing nonbelief. Some who have left the religion of their family of origin experience rejection by family members, and clients often want to express and explore the pain they experience as a result of their choice. To practice ethically and effectively with these clients, therapists must gain competence in making assessments and in

providing treatment for these people. The assessment process is crucial in identify- ing any religious or spiritual concerns, both positive and negative, that an individ- ual may have and assessing whether these beliefs, past or present, provide them with meaning or with distress. If clients say they want to talk about religious or nonreligious matters, these concerns should be addressed in their therapy. Sahker (2016) provides a theoretical model of assessment, conceptualization, and inter- vention that can be an effective clinical tool in working with the nonreligious.

Religious Teachings and Counseling

Religious beliefs and practices affect many dimensions of human experience, both positively and negatively. At their best, both counseling and religion are able to foster healing through an exploration of self by learning to accept oneself; by giv- ing to others; by forgiving others and oneself; by admitting one’s shortcomings; by accepting personal responsibility; by letting go of hurts and resentments; by dealing with guilt; and by learning to let go of self-destructive patterns of think- ing, feeling, and acting.

Although religion and counseling are comparable in a number of respects, some key differences exist. For example, counseling does not involve the impo- sition of counselors’ values on clients, whereas religion mostly involves teaching doctrines and beliefs that individuals are expected to accept and practice. Ethi- cally, it is important to monitor yourself for subtle ways that you might be inclined to introduce your values in your counseling practice. For instance, you might influence clients to embrace a religious perspective, or you might influence them to give up certain beliefs that you think are no longer functional for them. Keep in mind that it is the client’s place to determine what specific values to retain, replace, or modify.

Personal Beliefs and Values of Counselors

As we have mentioned, if mental health practitioners are to competently and eth- ically serve the diverse needs of clients, they must be capable and prepared to look at spirituality and religion when these are important to their clients. John- son (2013) believes that therapists would do well to spend time reflecting on their own spiritual identity and journey, especially on experiences that were emotion- ally intrusive and fostered reactivity. If therapists understand and have worked through their spiritual emotional baggage, they can listen to their clients’ spiritual experiences, values, and practices without becoming emotionally reactive and imposing their personal agenda on clients.

Your Personal Stance As you examine your own position on the place of spiritual and religious values in the practice of counseling, reflect on these questions:

What connection, if any, do you see between spirituality, religion, and the problems of the client?
Do you think it is ever justified for clinicians to introduce or teach their reli- gious or spiritual values to clients and to base their clinical practice on these values? Explain.
How would you describe the influence of religion or spirituality in your life? What relevance might this have to the way you practice counseling?
How would you manage situations in which your beliefs about religion or spirituality conflict with those of your client?
Are therapists forcing their values on their clients when they decide what top- ics can be discussed? Explain.
If you have no religious or spiritual convictions, how would you work with clients who hold strong views in these areas?
Is there an ethical issue when a counseling agency that is attached to a church imposes the church’s teachings or religious dogma as part of their counseling practices? Explain.
To what degree are you willing to collaborate with clergy or indigenous heal- ers if it appears that clients have questions you are not qualified to answer?
How does a counselor in a public school deal with spiritual or religious issues that students may bring up? Do parents need to be informed that spiritual issues may be discussed in counseling?

An Ethical Decision-Making Process Model

Barnett and Johnson (2011) describe an ethical decision-making process model to determine whether religious or spiritual beliefs may be clinically salient, and if so, to identify ethical principles and standards in determining how to proceed. These key points of their model can be applied when dealing with ethical dilemmas pertaining

to a •

• •

client’s religious or spiritual beliefs and concerns in the therapeutic context:

Respectfully assess a client’s religious or spiritual beliefs at the beginning of the counseling relationship. Tailor this assessment to the individual client, the psychotherapy context, and the client’s preference for considering these concerns.

Carefully assess any connection between a client’s presenting problem and religious or spiritual beliefs. Be aware of the wide range of religious and spiritual beliefs and practices in various cultural groups by engaging in both didactic and experiential learning.

Weave the results of an initial assessment into the informed consent process. If religious or spiritual concerns will be explicitly addressed in therapy, develop a treatment plan that incorporates this focus and obtain your client’s informed consent.

Honestly consider your potential countertransference to a client’s religious beliefs and practices. If your countertransference might undermine the thera- peutic endeavor or harm the client, seek consultation. Evaluate your competence in a given case by reviewing the professional litera- ture, practice guidelines, laws, and ethics standards pertinent in working with a client’s religious concerns.

Consult with experts in the area of religion and spirituality in the practice of psychotherapy. Colleagues with expertise in religion and spirituality can help you explore your countertransference involving a client’s spirituality or religion.

Multicultural Terminology

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the word culture, interpreted broadly, is associated with a racial or ethnic group as well as with gender, age, religion or spirituality, economic status, nationality, physical capacity or disability, and affectional or sexual orientation. Pedersen (2000) describes culture as including demographic variables such as age, gender, and place of residence; status variables such as social, educational, and economic background; formal and informal affiliations;

and the ethnographic variables of nationality, ethnicity, language, and religion. considering culture from this broad perspective provides a context for understanding that each of us is a member of many different cultures. culture can be considered as a lens through which life is perceived. each culture, through its differences and similarities, generates a phenomenologically different experience of reality (Diller, 2015). choudhuri, santiago-rivera, and garrett (2012) define culture as a “total way of life held in common by a group of people who share similarities in speech, behavior, ideology, livelihood, technology, values, and social customs” (p. 34).

Ethnicity is a sense of identity that stems from common ancestry, history, nationality, religion, and race. this unique social and cultural heritage provides cohesion and strength. it is a powerful unifying force that offers a sense of belonging and sharing based on common- ality (Lum, 2004; Markus, 2008).

an oppressed group refers to a group of people who have been singled out for differential and unequal treatment and who regard themselves as objects of collective discrimination. these groups have been characterized as subordinate, dominated, and powerless.

Multiculturalism is a generic term that indicates any relationship between and within two or more diverse groups. a multicultural perspective takes into consideration the specific values, beliefs, and actions influenced by a client’s ethnicity, gender, religion, socioeconomic status, political views, sexual orientation, physical and mental/cognitive abilities, geographic region, and historical experiences with the dominant culture. Multiculturalism provides a con- ceptual framework that recognizes the complex diversity of a pluralistic society, while at the same time suggesting bridges of shared concern that bind culturally different individuals to one another (Pedersen, 1991, 2000).

Multicultural counseling “can be operationally defined as the working alliance between counselor and client that takes the personal dynamics of the counselor and client into consideration alongside the dynamics of the cultures of both of these individuals” (Lee & Park, 2013, p. 5). from this perspective, counseling is a helping intervention and process that defines contextual goals consistent with the life experiences and cultural values of clients, balancing the importance of individualism versus collectivism in assessment, diagnosis, and treatment (sue & sue, 2013).

Cultural diversity refers to the spectrum of differences that exists among groups of people with definable and unique cultural backgrounds (Diller, 2015).

Diversity refers to individual differences on a number of variables that can potentially put clients at risk for discrimination based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status. both multiculturalism and diversity have been politicized in the United states in ways that have often been divisive, but these terms can equally represent positive assets in a plu- ralistic society.

Cultural pluralism is a perspective that recognizes the complexity of cultures and values the diversity of beliefs and values. Lee and Park (2013) add that “counselors must provide services that help people to solve problems or make decisions in the midst of such sweeping demographic and sociological change” (p. 5).

Cultural diversity competence refers to a practitioner’s level of awareness, knowledge, and interpersonal skills needed to function effectively in a pluralistic society and to intervene on behalf of clients from diverse backgrounds (sue & sue, 2013).

Cultural empathy pertains to therapists’ awareness of clients’ worldviews, which are acknowledged in relation to therapists’ awareness of their own personal biases (Pedersen, crethar, & carlson, 2008).

Culture-centered counseling is a three-stage developmental sequence, from multicul- tural awareness to knowledge and comprehension to skills and applications. the individual’s or group’s culture plays a central role in understanding their behavior in context (Pedersen, 2000).

Cultural awareness includes a compassionate and accepting orientation that is based on an understanding of oneself and others within one’s culture and context (crethar & Win- terowd, 2012).

Social justice work in counseling involves the empowerment of individuals and family systems to better express their needs as well as to advocate on their behalf to address inequi- ties and injustices they encounter in their community and in society at large (toporek, Lewis, & crethar, 2009). counseling from a social justice perspective involves being aware of and addressing the realities of oppression, privilege, and social inequities.

Cultural tunnel vision is a perception of reality based on a very limited set of cultural experiences. Culturally encapsulated counselors define reality according to a narrow set of cultural assumptions and fail to evaluate other viewpoints, making little attempt to under- stand and accept the behavior of others.

Globally literate counselors display a cultural curiosity that is characterized by an openness to engaging in new cultural experiences. global literacy goes beyond tolerance of diverse cultures and worldviews; it promotes mutual respect and understanding (Lee, 2013b).

Stereotypes are oversimplified and uncritical generalizations about individuals who are identified as belonging to a specific group. such learned expectations can influence how counselors see the client.

Racism is any pattern of behavior that, solely because of race or culture, denies access to opportunities or privileges to members of one racial or cultural group while perpetuating access to opportunities and privileges to members of another racial or cultural group (ridley, 2005). racism can operate on individual, interpersonal, and institutional levels, and it can occur intentionally or unintentionally.

Unintentional racism is often subtle, indirect, and outside our conscious awareness; this can be the most damaging and insidious form of racism (sue, 2005). Practitioners who presume that they are free of any traces of racism seriously underestimate the impact of their own socialization. Whether these biased attitudes are intentional or unintentional, the result is harmful for both individuals and society.

Cultural racism is the belief that one group’s history, way of life, religion, values, and traditions are superior to others. this allows for an unequal distribution of power to be justi- fied a priori (sue, 2005).

Microaggressions are persistent verbal, behavioral, and environmental assaults, insults, and invalidations that often occur subtly and are difficult to identify (choudhuri et al., 2012). they usually involve demeaning implications and may be perpetrated against others on the basis of their race, gender, sexual orientation, or ability status.

There is some concern about how to refer appropriately to certain racial and ethnic groups as preferred names tend to change. For instance, some alternate names for one group are Hispanic, Latino (Latina), Mexican American, or Chicana (Chicano). Practitioners can show sensitivity to the fact that a name is important

Multicultural counseling competencies

Counselor Awareness of Own Cultural Values and Biases

With respect to attitudes and beliefs, culturally competent counselors: • are sensitive to cultural group differences because they possess self-awareness of

their own cultural heritage and identity. • are aware of how their personal attitudes and beliefs about people from different

cultural groups may facilitate or hamper effective counseling. • are aware of their own racist, sexist, heterosexist, or other detrimental attitudes and

beliefs. • are able to recognize the limits of their multicultural competencies and expertise. • recognize their sources of discomfort with differences that exist between themselves

and clients in terms of race, ethnicity, culture, gender, sexual orientation, and other sociodemographic variables.

With respect to knowledge, culturally competent counselors: • have specific knowledge about their own racial and cultural heritage and how it

personally and professionally affects their definitions of and biases about normality/

abnormality and the process of counseling. • possess knowledge and understanding about how oppression, racism, discrimina-

tion, and stereotyping affect them personally and in their work. • possess knowledge about their social impact on others. they are knowledgeable

about communication style differences, how their style may clash or foster the coun- seling process with persons of color or others different from themselves, and how to anticipate the impact it may have on others.

consider clients as individuals within a cultural context.

With respect to skills, culturally competent counselors: • seek out educational, consultative, and training experiences to improve their under-

standing and effectiveness in working with culturally different populations. • are constantly seeking to understand themselves as racial and cultural beings and

are actively seeking a nonracist identity.

Understanding the Client’s Worldview
With respect to attitudes and beliefs, culturally competent counselors: • are aware of their negative and positive emotional reactions toward other racial and

ethnic groups that may prove detrimental to the counseling relationship. they are willing to contrast their own beliefs and attitudes with those of their culturally dif- ferent clients in a nonjudgmental fashion.

are aware of stereotypes and a monolithic perspective they may hold toward other racial and ethnic minority groups.

With respect to knowledge, culturally competent counselors: • possess specific knowledge and information about the particular client group with

whom they are working. • understand how race, culture, ethnicity, and so forth may affect personality for-

mation, vocational choices, manifestation of psychological disorders, help-seeking

behavior, and the appropriateness or inappropriateness of counseling approaches. • understand and have knowledge about sociopolitical influences that impinge on the

lives of racial and ethnic minorities.

With respect to skills, culturally competent counselors: • familiarize themselves with relevant research and the latest findings regarding

mental health and mental disorders that affect various ethnic and racial groups. they should actively seek out educational experiences that enrich their knowledge, understanding, and cross-cultural skills for more effective counseling behavior.

become actively involved with minority individuals outside the counseling setting so that their perspective of minorities is more than an academic or helping exercise.

III. Developing Culturally Appropriate Intervention Strategies and Techniques

With respect to attitudes and beliefs, culturally competent counselors: • respect clients’ religious and spiritual beliefs and values, including attributions and taboos, because these affect worldview, psychosocial functioning, and expressions

of distress. • respect indigenous helping practices and respect help-giving networks among com-

munities of color. • value bilingualism and do not view another language as an impediment to

counseling.

With respect to knowledge, culturally competent counselors: • have a clear and explicit knowledge and understanding of the generic characteristics

of counseling and therapy and how they may clash with the cultural values of vari-

ous cultural groups. • are aware of institutional barriers that prevent minorities from using mental health

services. • have knowledge of the potential bias in assessment instruments and use procedures

and interpret findings in a way that recognizes the cultural and linguistic character-

istics of clients. • have knowledge of family structures, hierarchies, values, and beliefs from various

cultural perspectives. they are knowledgeable about the community where a partic-

ular cultural group may reside and the resources in the community. • are aware of relevant discriminatory practices at the social and the community level

that may affect the psychological welfare of the population being served.

With respect to skills, culturally competent counselors: • are able to engage in a variety of verbal and nonverbal helping responses. they are

able to send and receive both verbal and nonverbal messages accurately and appro- priately. they are not tied to only one method or approach to helping but recognize that helping styles and approaches may be culture bound.

acquire skills that are consistent with the life experiences and cultural values of their clients.
are able to exercise institutional intervention skills on behalf of their clients. they can help clients determine whether a problem stems from racism or bias in others so that clients do not inappropriately personalize problems.
are not adverse to seeking consultation with traditional healers or religious and spir- itual leaders and practitioners in the treatment of culturally different clients when appropriate.
take responsibility for interacting in the language requested by the client and, if not feasible, make appropriate referrals.
have training and expertise in the use of traditional assessment and testing instruments.
attend to and work to eliminate biases, prejudices, and discriminatory contexts in conducting evaluations and providing interventions and develop sensitivity to issues of oppression, sexism, heterosexism, elitism, and racism.
take responsibility for educating their clients to the processes of psychological inter- vention, such as goals, expectations, legal rights, and the counselor’s orientation.

for a more detailed description of these competencies, see sue and sue (2013, chap. 2).

The case of Talib

talib, an immigrant from the Middle east, is a graduate student in a counseling program. Dur- ing many class discussions, his views on gender roles become clear, yet he expresses his beliefs in a respectful and nondogmatic fashion. talib’s attitudes and beliefs about gender roles are that the man should be the provider and head of the home and that the woman is in charge of nurturance, which is a full-time job. although not directly critical of his female classmates, talib voices a concern that these students may be neglecting their family obligations by pursuing a graduate education. talib bases his views not only on his cultural background but also by citing experts in this country who support his position that the absence of women in the home has been a major contributor to the breakdown of the family. there are many lively discussions between talib and his classmates, many of whom hold very different attitudes regarding gen- der roles.

halfway through the semester, his instructor, Dr. berny, asks talib to come to her office after class. Dr. berny tells talib that she has grave concerns about him pursuing a career in counseling in this country with his present beliefs. she encourages him to consider another career if he is unable to change his “biased convictions” about the role of women. she tells him that unless he can open his thinking to more contemporary viewpoints he will surely encounter serious problems with clients and fellow professionals.

if you were one of talib’s classmates, what would you want to say to him?
What assumptions underlie Dr. berny’s advice to talib?
if you were a faculty member, what criteria would you use to determine that students are not suited for a program because of their values?
how would you approach a person whose views seem very different from your own? how would you respond to talib?

Commentary. Dr. berny seemed to assume that because talib expressed strong convictions he was rigid and would impose his values on his clients. she did not communicate a respect for his value system along with her concern that talib might impose his values on clients.

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