INTRODUCTION TO CLINICAL MENTAL HEALTH COUNSELING AND THE UNDERLYING DYNAMICS OF PRACTICE LISA LOPEZ LEVERS | DEBRA HYATTBURKHART 3
This chapter provides an introduction to clinical mental health counseling (CMHC). Important underlying dynamics of CMHC practice are identified and explored. The chapter offers a foundation for understanding the individual from a bioecological perspective, as well as for appreciating the delivery of mental health services from more contemporary community-based and systems-of-care models. This chapter sets the stage for understanding important dynamics of CMHC practice that are relevant across all of the chapters in the textbook. The following Council for Accreditation of Counseling and Related Educational Programs (CACREP) standards are addressed in this chapter: CACREP 2016: 2F1.a, 2F1.b, 2F3.a, 2F3.f, 2F3.i, 2F5.a, 5C1.a, 5C1.b
CACREP 2009: 2G1.a, 2G3f, 2G3.h, 2G5.a, 2G5.d, 2G3.h, 2G5.a
LEARNING OBJECTIVES
After reviewing this chapter, the reader should be able to: 1. Develop an introductory awareness of the major constructs and dynamics pertaining to the practice of CMHC; 2. Identify the relevance of a bioecological perspective concerning individuals who seek CMHC services; and, 3. Explain the importance of community-based and systems-of-care models in the practice of CMHC.
A PRELIMINARY INTRODUCTION TO THE CMHC FIELD
4 The purpose of this chapter is to offer an overview of the profession of CMHC and to do so in a way that illuminates some of the relevant dynamics that underlie the practice of CMHC. Details about the counseling profession, and specifically CMHC, are provided in Chapter 2 of this textbook. In the current chapter, we present content that links the practice of CMHC with the importance of an ecological perspective of the individual and to the current landscape of integrated healthcare. Understanding this link is integral to understanding the context for the profession that is presented in Chapter 2; further, it is relevant to the clinical practice and professional issues that are discussed in every subsequent chapter in this book. The clinical
landscape has changed dramatically since the early genesis of the counseling profession. The field has moved from the psychodynamic influences of the late 19th and early 20th century pioneers, to both behavioral and humanistic influences by the mid-20th century, to later systemic and more community based approaches to care. We believe that it is important to orient the preservice training of clinical mental health counselors to an understanding of these important changes and trends and how these dynamics have taken root in practice and service provision. We have framed these issues, in this first chapter, as advanced organizers to assist students in anticipating how these important matters interface with various aspects of their CMHC training. Discussions of these essential factors appear in the following sections of this introductory chapter: (a) Contemporary Counseling Ethos, (b) Human Ecology and Systems, (c) Professional and Therapeutic Tensions and Dynamics, and (d) Relevance of Understanding the Council for the Accreditation of Counseling and Related Educational Programs Standards. We believe that if new master’s-level students are afforded an early introduction to these key strands of information, which have been integrated throughout the chapters of this textbook, it can enhance their overall learning
experience. These discussions are followed by a brief integrative summary of the chapter, which echoes the overarching message that it is important for CMHCs to understand the big picture and the underlying dynamics and tensions of the CMHC field before drilling down to other basic and pertinent details about the profession.
CONTEMPORARY COUNSELING
ETHOS In its beginnings, the counseling profession stressed a client-centered, humanistic, biopsychosocial, and strength-based approach to working with people. Along the pathway toward the field of counseling developing a more robust professional identity, this trajectory was detoured, necessarily, toward a more problem-focused, medical/illness-based modality of treatment. We say “necessarily,” because the playing field for counselors began to be defined more narrowly, beginning in the 1960s, as a result of licensure regulations in other psychosocial helping professions. This increasingly became the case, in the 1970s through the 1990s, due to the advent of managed care and third-party reimbursement requirements (managed care and third-party reimbursement are discussed in detail in Chapter 12 of this textbook). Eventually, if counselors wished to have parity with other 5 helping professions, it was necessary to push
for licensure, and the process required a stronger diagnostic and pathology-focused orientation in order to meet the demands of regulatory bodies and to fit within the established view of mental health treatment (counselor licensure is discussed in detail in Chapter 8 of this textbook, and professional advocacy issues are addressed in Chapter 12). This is not to suggest an either/or approach, in terms of counseling being either wellness or psychopathology oriented, because we believe that it functions as both (the professional roles of clinical mental health counselors are discussed in detail in Chapter 10). In various chapters of this textbook, we address the tensions that exist between the potential benefits and detriments of diagnosis. However, with the dawn of the 21st century, we see a strengthening movement to return to the roots of counseling as a collaborative, salutogenic, systemssensitive endeavor, which is dynamic enough to account for the entire continuum of human experience. Whereas psychology focuses more on the individual, and social work focuses more on systems, we view professional counseling as a unique enterprise in that professional counselors often focus on the interface between the individual and his or her multiple environments, inclusive of social systems and culture. We believe that this is a strength of the
counseling model that has not been highlighted enough. Following this organic aspect of our professional history, we endorse the movement toward returning to our more existentially oriented roots, with multiple emphases on authenticity in and the positionality of the counselor–client relationship in the here and now.
HUMAN ECOLOGY AND SYSTEMS
We believe that an ecological perspective of the individual, along with a focus on the integrated systems of care in clinical mental health endeavors, provides clinical mental health counselors with knowledge and skills that can help them to work and innovate more dynamically in their practice as clinical mental health counselors. In the following subsections, we offer brief descriptions of the bioecological model of human development and integrated healthcare and behavioral healthcare models. These discussions directly connect with related topic-specific discussions in the subsequent chapters of this textbook. Bioecological Model of Human Development For many decades, counseling, psychological, and psychiatric services have focused almost exclusively on the individual. It was not until about the 1970s that professional attention shifted to the important reciprocal dynamics between the individual’s personal scope-of-existence and broader-
yet interconnected environments. Bronfenbrenner (1979, 2004) first developed his human ecological systems theory in the 1960s, as he was assisting the federal government in the design of the Head Start Program. Later in his life, he added a temporal component to his theory and renamed it as the Bioecological Model or Theory. 6 FIGURE 1.1
Bronfenbrenner’s bioecological model of human development. SOURCE: Santrock, J. W. (2011). A topical approach to life-span development. New York, NY: McGraw-Hil Education. The bioecological model posits that every individual operates within multiple environments and that the individual is nested within a series of proximal (closer or nearby) as well as more distal (farther away or at a greater distance) social and cultural systems of influence. Bronfenbrenner (1979, 2004) identified the following levels of environmental influences on and in interaction with human development: the microsystem, the mesosystem, the exosystem, the macrosystem, and the chronosystem. As illustrated in Figure 1.1, each of these environmental levels has distinct influences on the developing person. Although Bronfenbrenner’s initial research was oriented toward the developing child, as his theory evolved, especially with the addition of time as an important element, the model has been
considered to be applicable across the lifespan. The defining aspect of the microsystem encompasses the individual, inclusive of the particular individual’s attributes, temperament, age, gender, and other personal characteristics. But the microsystem also comprises the environmental context that includes social systems and social spaces that are most proximal to the individual. These include social units such as family, school, workplace, peers, close friends, and some healthcare 7 providers; the microsystem also includes proximal spaces such as places of worship, community centers, the nearby neighborhood, and play or work areas. The mesosystem constitutes any person, social unit, or space that facilitates interaction between systems within the microsystem and also that facilitates interaction between the microsystem and the exosystem. This could include a teacher’s conference between a child’s parents and the school (both within the microsystem); it also could involve a primary healthcare physician (microsystem) referring a patient needing a procedure to a specialist (mesosystem), who then arranges for clinic or hospital care (exosystem) for the patient. The exosystem includes social influencers who are a bit more distal, such as friends of the family, neighbors who live a few blocks
away rather than next door, the mass media, and social or legal services with which the individual or family may be involved. The social units comprising the exosystem do not have as direct an influence on the individual as those in the microsystem, but these more distal influencers still can have a profound systemic effect on the person. The macrosystem, which is most distal to the individual, encompasses attributes of the society. These include social attitudes, ideologies, and cultural norms of the particular society at large. It is this feature of the bioecological model that provides its cultural robustness or elasticity. Depending upon the culture in which the individual lives, the macrosystemic features may have differing impacts upon how the other systems influence the person, including at the microsystemic level. Finally, the chronosystem comprises temporal influences upon the individual. This includes both personal time and sociohistorical time. In other words, the chronosystem represents both the lifespan of the individual, from birth to death, as well as the sociohistorical era in which the person lives. Examples that illustrate the latter would be the impact of the great American depression on people living in the United States during that time (beginning in 1929 and lasting approximately a decade), or the
effects of the technological era on digital natives living during the current time—and the sociohistorical influences may be different among people living in a developed or modern context versus those living in a developing or traditional context. Several constructs are important in gleaning a further appreciation of the elegance of this model. First is the notion of reciprocity. The bidirectional arrows shown in Figure 1.1 represent the reciprocal dynamic between the individual and the various systemic environments: The individual has an impact on his or her environment at the same time that the environment has an impact on the individual. Concomitant with the importance of an awareness of reciprocity is an understanding of risk factors and protective factors. The potential for risk factors exists across all of the biopsychosocial systems for every human being. Risk factors may be as pervasive as poverty or as singular as someone who is ill not having transportation to a doctor’s appointment on a particular day. The potential also exists, in the same way, for protective factors across the person’s multiple environments. Protective factors may include nurturing parents, reliable and supportive social contacts, or equitable access to education and healthcare. Issues pertaining to risk factors and protective factors may have a direct
relationship with social justice issues, which also are relevant to the work of clinical mental health counselors. Some of the very groups of people experiencing a greater proportion of risk factors (e.g., poverty and community violence) also 8 may experience the least environmental protective factors (e.g., access to education and access to adequate healthcare). The impact of such social inequities for individual clients and within their social networks are important considerations for clinical mental health counselors (matters of access, equity, culture, and systemic influences are discussed in detail in Chapters 9 and 11). TIP
FROM THE FIELD 1.1
UNDERSTANDING RISK AND PROTECTIVE FACTORS
If we think about the clients we serve, the importance of understanding risk and protective factors begins to come into sharper focus. If we are able to identify certain risk factors faced by clients, we may be able to find ways or resources for mitigating or even extinguishing these risk factors. Likewise, if we work with clients who have few or no existing protective factors, we can find ways to advocate for clients’ needs to be met. Understanding these elements of the bioecological model leads to a brief discussion of another important aspect of the contemporary counseling ethos, especially to the practice of CMHC,
that is, the importance of advocacy and social justice. Advocacy and Social Justice Client advocacy, especially relative to social justice, has gained increasing importance in the professional counseling field over the last several decades (Kiselica & Robinson, 2011; Lewis, Ratts, Paladino, & Toporek, 2011; Ratts & Hutchins, 2009; Toporek, 2011). These two systemic concerns are interwoven throughout various chapters in this textbook and involve advocating for clients, particularly vulnerable and marginalized clients, around the intersectionality of race/ethnicity, gender, ability, and class/income issues. An awareness of and sensitivity to these important cultural humility concerns (Hook, Davis, Owen, & DeBlaere, 2018) are paramount to the work of all helping professionals, including clinical mental health counselors. Integrated Healthcare and Behavioral Healthcare Models Integrative healthcare, the incorporation of behavioral health practices into medical services, including complementary and alternative medical (CAM) practices (e.g., acupuncture, tai chi, yoga, medicinal herbs, and mindfulness techniques), has been a focus of public health efforts for at least a decade (American Psychiatric Association [APA] & Academy of Psychosomatic Medicine [APM], 2016). Integrated
healthcare is broadly viewed as a mechanism for improving individuals’ experiences of care (Heath, Wise, & Reynolds, 2013). The President’s New Freedom Commission on Mental Health (2008) final report highlighted the need for increased coordination among primary care physicians, mental health providers, and other stakeholders, such as schools and community organizations, in order to improve treatment outcomes for those experiencing mental health issues. 9 As the field of professional counseling has continued to respond to this call for integrative services, we have seen the development of a number of approaches to achieving this goal. Integration of services generally occurs in one of two ways. One way is that mental health services are integrated into physical health services. An example of this approach is that of a patient whose primary complaint to his or her physician is fatigue, sleeplessness, and an overall sense of depression. Most physicians in this case likely would order tests to check for physical/medical causes for the symptoms (e.g., thyroid functioning, blood counts); this has been the traditional allopathic or biomedical approach to providing care. In a more integrated approach, the physician also might delve into the patient’s psychosocial systems, explore current problems, and offer a referral for counseling
services related to the patient’s life circumstances and stressors. The physician would then follow up with the patient, the counselor, and any other providers who have joined the treatment team to coordinate and monitor progress toward the goal of reducing symptoms and improving functioning. An alternative approach to care occurs essentially in reverse of what was just presented. An individual seeks services from a counselor because of the same presenting issues of depression. Here, the counselor would proceed with developing a treatment plan to help the client improve his or her functioning and would refer the client to a physician in order to rule out possible medical causes for the complaints. This integration of treatment, in whichever direction it originates, helps to reduce common issues, such as failure to treat comorbid physical and mental health conditions, lack of access to care due to stigma, and an overall underutilization of the mental health system (Butler et al., 2008).
CASE ILLUSTRATION 1.1
LISTENING TO THE CLIENT Mrs. Smith was referred to the community mental health clinic upon discharge from a psychiatric unit. She was assigned to a licensed clinical mental health counselor, Isabella, who conducted a thorough intake evaluation. Although Mrs. Smith already carried a diagnosis of
Schizophrenia, Isabella did not feel that Mrs. Smith fully met the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for the disorder. In addition, Isabella, who had a specialty in psychiatric rehabilitation and a lot of experience working with severe psychiatric disorders, did not find Mrs. Smith’s demeanor and behaviors to fit, qualitatively, with what Isabella had come to understand from previous clients’ lived experiences of the disorder. At the end of the appointment, they rescheduled a counseling session for the following week, as well as an appointment to see the agency psychiatrist immediately following the counseling appointment. At that same time, Isabella asked Mrs. Smith to bring her prescription bottles with her to the next appointment, as she was unable to tell Isabella the names of her medications. Isabella was shocked the following week when Mrs. Smith brought her meds to the appointment in a shopping bag. Isabella waded through the many medications, writing their names into the client file so that the psychiatrist could see them, but also noting to herself that some of the meds were contraindicated with some of the other meds and that there was a high risk of potentiation of side effects between some of the prescriptions. 10 Alarmed, Isabella reported to the psychiatrist between
Mrs. Smith’s counseling session and her psychiatricintake appointment. The psychiatrist shared Isabella’s concern, and they agreed that Isabella would call Mrs. Smith’s primary care physician (Isabella already had obtained signed consent from the client). When Isabella called the physician to inquire about whether he was aware of the number of medications that had been prescribed to the client, he was rude and demeaning and kept asking “What is your degree?”
The physician abruptly terminated the conversation without providing the requested information. Although the physician had been abrasive, Isabella knew that it was in the client’s best interest that she not take it personally, and she decided to pursue the most professional course of action. Isabella waited until Mrs. Smith was finished with the psychiatrist. She then asked Mrs. Smith to remain in Isabella’s office, while Isabella consulted with the psychiatrist and explained to the psychiatrist what had transpired. The psychiatrist immediately went into action, ordering appropriate blood testing for Mrs. Smith and having her stop some of the psychotropic medications. Subsequently, based upon the results of the tests, the psychiatrist had Mrs. Smith stop all of her medications, with the exception of her mediation for diabetes. The psychiatrist and counselor continued to
monitor Mrs. Smith, along with physicians to whom the psychiatrist had referred Mrs. Smith, and they watched her condition improve. Finally, one day some time later, when Mrs. Smith arrived for her counseling appointment, with tears in her eyes, she hugged Isabella in the waiting room and said “Thank you! You have given me my life back. I tried to tell them that I wasn’t Schizophrenic, that I just needed my diabetes medication. But they wouldn’t listen to me. They just put me in the hospital. But you listened to me, and now I’m me again. I have my life back.” The Affordable Healthcare Act of 2012 and subsequent Medicaid expansion efforts in many states allowed for the development of programs that reconceptualize the provision of services. Programs that incorporated community-based services, interdisciplinary treatment teams, in-home family services, and innovative technologies have been developed to bridge the gaps among all of the treatments needed for those who are experiencing mental health issues (Mechanic, 2012). Community-based treatments fill the need created by the closure of residential facilities and state psychiatric hospitals, upon which society previously relied, to assist those with mental health issues. It is important to note that integrated care not only is happening between the realms of physical and
mental health. School and mental health partnerships are increasing the number of children and adolescents who receive mental health services by reaching them within the school setting. These partnerships are helping to reach ethnic minority groups, those without transportation to traditional services, individuals who may be dissuaded by stigma, and those without financial resources (Acharya et al., 2017). 11 Schools provide an avenue by which to reach millions of children each day. When the partnership is expanded to include physical health, case management services, and family interventions, among others, children have a greater chance to achieve lasting improvement than if they received stand alone treatment outside of the school environment. By combining case management/social work services with professional counseling interventions, medication management, physical health treatment, and social/community connection services, we can approach an individual’s needs holistically, which bodes for better outcomes. When we consider the biopsychosocial nature of human existence, we also must consider that client issues do not occur exclusively in one domain. In order to facilitate lasting recovery, we must employ treatment interventions that span domains and provide a
comprehensive view of the issues presented. This integrated approach to treatment is referenced across chapters of this textbook. PROFESSIONAL AND THERAPEUTIC TENSIONS AND DYNAMICS We believe that it is important for CMHC students to develop an understanding, as early in their training as possible, of some of the field based tensions that they eventually will encounter. Therefore, each chapter in this textbook identifies professional and therapeutic tensions and dynamics associated with working with clients in the CMHC context. For example, in the chapter on self-care, the author addresses how empathy for one’s clients presents the tension between a necessity for effectiveness in treatment and the possibility of vicarious traumatization. We believe that by looking at such clinical tensions or challenges in the early stages of training, counseling students can develop a greater awareness of and sensitivity to the kinds of dilemmas, and potential ethical dilemmas, that are sure to arise with clients at the time that the students begin their clinical fieldwork experiences. We further believe that exploring the construct of “clinical tensions” is highly relevant, as it offers insight into how counselors negotiate the oftentaut spaces between, and maintain some semblance of balance within, the competing interests that often
intricately affect the lived experiences of clients. We have identified relevant tensions, and these are discussed within the text of each chapter.
RELEVANCE OF UNDERSTANDING THE COUNCIL FOR THE ACCREDITATION OF COUNSELING AND RELATED EDUCATIONAL PROGRAMS STANDARDS
The CACREP (2016) is the major accrediting body for counselor education programs (CEPs). We believe that it is critical for entry-level students to understand the logic of the educational, professional, and ethical standards that they are expected to learn, master, and embrace. Therefore, each chapter in this textbook highlights content-relevant CACREP Standards, emphasizing both the 2009 and the 2016 Standards. Our logic in asking authors to address the CACREP standards that are related to the specific chapter is twofold. First, our intention is to offer as much support as possible, within the limitations of a textbook, to instructors in meeting the standards in this 12 course. Second, we believe that it assists students to acquire the requisite competencies if they can understand what is being required of them in the process of becoming competent and ethical practitioners. We have identified both 2009 and 2016 standards because some programs may still be making the
transition. Students and instructors alike can compare the two sets regarding each topic, viewing them as a tension or on a developmental continuum, identifying the similarities and differences, and from a certain perspective, understanding some of the nuanced ways in which the counseling profession has evolved. An additional emphasis is in assisting the students to understand how important it is for CEPs to adhere to the CACREP Standards. CONCLUSION This chapter has offered an introduction to some of the key elements that epitomize the CMHC profession and that serve as underlying dynamics in CMHC practice. In so doing, the chapter also has mapped out the most efficacious constructs involving the practice of CMHC and that appear across the subsequent chapters in this textbook. By focusing on a preliminary orientation to current CMHC concerns, trends, settings, and practice-based issues, the major aim of this chapter was to provide an impressionistic picture of contemporary clinical mental health counselor. In the pursuit of this goal, more broadly, this chapter, along with the other chapters of the textbook, frames a type of human ecology, social justice advocacy, and critical systems thinking that advocates for the practice and profession of CMHC. We have endeavored to offer a big-picture perspective of
CMHC issues in this chapter, in a way that enables clinical mental health counselors to connect the proverbial dots, as they emerge or appear, across the content areas that are clinically and professionally relevant to the practice of CMHC. We believe that it is important to understand the overarching themes as well as the underlying dynamics and tensions of the CMHC field before drilling down to other basic and pertinent details about the profession that are found in Chapter 2.