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Rehabilitation and Mental Health Counseling

Rehabilitation
The action of restoring someone to health or normal life through training and therapy after
imprisonment, addiction, or illness

History and Background

Rehabilitation counseling emerged as a distinct profession in 1920 with the passage of the Smith-
Fess Act, which established the federal-state vocational rehabilitation (VR) program. The training
provision of the Vocational Rehabilitation Act Amendments of 1954 (PL 565) further spurred the
profession by allocating funding for the development of widespread master’s level rehabilitation
counseling training programs. This training provision, along with the research and demonstration
provision of PL 565, provided a strong foundation for the professionalization of rehabilitation
counselors.
Support for the effectiveness of graduate rehabilitation counselor training programs was
found through a series of studies conducted by Szymanski and colleagues as well as other
independent researchers who investigated the relationship of rehabilitation counselor education
and experience to client outcomes in Arkansas, Maryland, New York, and Wisconsin. Results
from these studies suggested that counselors with master’s degrees in rehabilitation counseling
(or closely related fields) produce better outcomes for clients with severe disabilities as
compared to counselors without such educational preparation. These findings underscored the
importance of mastering the knowledge and skill domains essential to rehabilitation counseling
practice through formal education.
As a result, in 1997 the Rehabilitation Act was amended to include the Comprehensive
System of Personnel Development (CSPD), which was designed to ensure that federal-state VR
programs employ rehabilitation counselors who hold the highest local or national certification
licensing credential for the field. This mandate required all new hires as well as currently
employed rehabilitation counselors to have or obtain a master's degree in rehabilitation
counseling and/or being able to obtain the national Certified Rehabilitation Counselor (CRC)
certificate.

Importantly, the professionalization of rehabilitation counseling has been shaped significantly by

graduate training programs that have, for many years, been grounded in providing students with
the knowledge and skills necessary for working with persons with physical and mental disabilities
within federal-state VR programs. This trend, however, has been changing as the scope of
disability groups broaden and the professional practice of rehabilitation counseling is no longer
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restricted to federal-state VR programs. Today, rehabilitation counselors work in various settings

including proprietary rehabilitation companies, private practice, private non-profit rehabilitation
facilities/organizations, insurance companies, medical centers or general hospitals, and
businesses/corporations, and are required to meet the diverse needs of a wide and more complex
spectrum of disability groups with various degrees of severity. While the central role of
rehabilitation counselors has not changed substantially, the specific functions of counselors do
vary according to their practice settings (public, private for profit, community- based
rehabilitation organizations, etc.) and the disability group being served. The diversity of
rehabilitation counseling functions has become increasingly apparent in recent studies
investigating the roles, functions, knowledge and skills of today’s rehabilitation counselors.

Definition
Rehabilitation counseling has been described as a process where the counselor works
collaboratively with the client to understand existing problems, barriers and potentials in order to
facilitate the client's effective use of personal and environmental resources for career, personal,
social and community adjustment following disability. In carrying out this multifaceted process,
rehabilitation counselors must be prepared to assist individuals in adapting to the environment,
assist environments in accommodating the needs of the individual, and work toward the full
participation of individuals in all aspects of society, with a particular focus on independent living
and work.

Philosophy
With the passage of the 1973 Rehabilitation Act Amendments emphasizing services to people
with severe disabilities, the philosophy of rehabilitation has evolved from an economic-return
philosophy to a disability rights philosophy. Issues related to consumerism have received
considerable attention, particularly in recent years, in the field of vocational rehabilitation. The
demand for consumerism was first reflected in the legislative arena with the passage of the 1973
Rehabilitation Act Amendments, when consumer involvement was mandated in the rehabilitation
planning process. Not surprisingly, the mandate that the Individualized Written Rehabilitation
Program (IWRP) be required by statute was the result of efforts by advocacy groups such as the
American Coalition of Consumers with Disabilities, and was the first time that consumers were
recognized by legal statute as equal partners in the rehabilitation process.
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More recently, the 1992 and 1998 Amendments to the Rehabilitation Act extended the active role
of consumers throughout the vocational rehabilitation process. For example, both Sections 101
and 102 of the 1992 Rehabilitation Act Amendments emphasize the importance of empowering
people with disabilities in selecting their own career goals and developing their own written
rehabilitation programs. The importance of empowerment continued with the passage of the 1998
Amendments to the Rehabilitation Act, as new provisions enhanced the collaborative relationships
between consumers and rehabilitation counselors throughout the vocational rehabilitation process
(e.g., enhancement of consumer informed choice and the cooperative development of the
Individualized Plan for Employment). These legislative and philosophical changes reflected
consumer discontent with a system viewed by many as paternalistic and disempowering. The
traditional hierarchical counseling structure, where the counselor occupies the power position, is
generally perceived by consumers as detrimental to the optimal rehabilitation of people with
disabilities. Active participation by both consumers and counselors is viewed as the most viable
alternative to the traditional helping relationship. This evolved philosophy of rehabilitation
emphasizes consumer involvement and empowerment, which should
lead consumers to take more responsibility and ownership in their vocational rehabilitation
program.
Goals of rehabilitation
Within the disability rights context, the goals of rehabilitationhave been identified as:
 Inclusion.
 Opportunity.
 Independence.
 Empowerment.
 Rehabilitation.
 Quality life.
Both rehabilitation professionals and consumers generally accept the notion that the goalsof the
rehabilitation process can be better achieved when there is maximum consumer involvement in
the development, implementation, and use of vocational rehabilitation services. The conceptof
consumer informed choice is intended to maximize the involvement of consumers in their
vocational rehabilitation programs. Rehabilitation counselors assist consumers in exercising
informed choice throughout the vocational rehabilitation process by:
 Providing consumers with information pertaining to various options (e.g., job development
service providers, vocational evaluation service providers, IPE development),
 Providing recommendations and professional opinions,
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 Providing consumers with information concerning the policies and procedures on service
provision (e.g., comparable benefits, licensure and accreditation of service providers).
Roles and Functions
Muthard and Salamone conducted the first study investigating the roles and functions of
rehabilitation counselors working in state VR programs – the dominant practice setting at that
time. Their results suggested that counselors divide their time equally among three areas
including:
 Counseling and guidance
 Clerical work, planning, recording, and placement
 Professional growth, public relations, reporting, resource development, travel, and
supervisory administrative duties.
Since this investigation, roles and functions studies have been conducted on a regular basis, with
several receiving support from the Commission on Rehabilitation Counselor Certification
(CRCC) and the Council on Rehabilitation Education (CORE).
For example, Leahy et al. conducted the most recent roles and functions study, which
involved a survey of a large random sample of certified rehabilitation counselors. This study
examined the perceived importance of major job functions and knowledge domains that underlie
contemporary rehabilitation counseling practice and credentialing. Results revealed seven major
job functions as central to the professional practice of rehabilitation counseling in today’s
practice environment including:
 Vocational counseling and consultation,
 Counseling interventions.
 Community-based rehabilitation service activities.
 Case management.
 Applied research.
 Assessment.
 Professional advocacy.
The vocational counseling and consultation function was composed of four sub factors including:
 Job development and placement
 Career counseling
 Employer consultation
 Vocational planning and assessment.
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The tasks associated with counseling interventions were organized into three sub factors
including:
 Providing individual, group, and family counseling
 Building consumer-counselor working relationships
 Helping consumers cope with specific psychosocial issues related to disabilities.
The community-based rehabilitation service function represents activities that involve
such tasks as:
 Researching resources and funding available in the community for consumers.
 Advocating for consumers and their families.
 Benefits counseling.
 Marketing rehabilitation services to the community.
The case management function involves activities such as:
 Obtaining written reports regarding client progress
 Developing rapport/referral network with physicians and other rehabilitation healt
professionals
 Reporting to referral sources regarding progress of cases
 Making financial decisions for caseload management.
The applied research function focuses primarily on applying research skills to professional
practice (e.g., reviewing clinical rehabilitation literature on a given topic or case problem). The
assessment function represents assessment activities such as selecting and administering
standardized tests and conducting ecological assessment. Finally, the professional advocacy
function involves applying disability-related policy and legislation to daily rehabilitation
practices.
Knowledge and Skill Domains
Rubin and Roessler proposed that in order for persons with disabilities to be effectively
served, rehabilitation counselors must operate as “sophisticated professionals” who
possess multiple skills and knowledge domains and have the ability to integrate a
multifaceted service delivery system. Leahy et al. identified six knowledge and skill
domains perceived by certified rehabilitation counselors as important for contemporary
rehabilitation counseling practice including:
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 Career counseling, assessment and consultation

 Counseling theories, techniques, and applications
 Rehabilitation services and resources
 Case and caseload management
 Healthcare and disability systems
 Medical, functional, and environmental implications of disability.
The career counseling, assessment and consultation services domain represents
knowledge in vocational consultation and employer services, job development/job placement,
and career counseling and assessment techniques. The counseling theories, techniques, and
applications domain represents knowledge in mental health counseling, group and family
counseling, individual counseling, psychosocial and multicultural counseling, and professional
issues. The rehabilitation services and resources domain represents knowledge related to
supported employment and school to work transition, independent living, benefits counseling,
healthcare and rehabilitation systems, and other community resources. The case and caseload
management domain represents knowledge related to principles of caseload
management,clinical problem-solving skills, case recording and documentation,
interdisciplinary teamwork, and conflict resolution strategies. The healthcare and disability
systems domain represents knowledge required to perform rehabilitation case management
functions in integrated disability management systems. The medical, functional and
environmental implications ofdisability domain represents knowledge related to medical and
functional limitations of disabilities and their vocational implications.

Credentialing
The Certified Rehabilitation Counselor (CRC) credentialing process was the first, and
considered to be the most, established certification mechanism in the counseling and
rehabilitation professions within the United States. The Commission on Rehabilitation
Counselor Certification (CRCC) was officially incorporated in January 1974 to conduct
certification activities on a nationwide basis. Since this time, over 23,000 qualified
professionals have participated in the certification process. Today, over 15,000 CRCs
are practicing in the United States and in several other countries.
The primary purpose of certification is to provide assurance to rehabilitation counseling
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clients that services will be provided in a manner that meets the national standards of quality.
Such standards are also considered by the profession to be in the best interest of the client. To
guide these standards, the CRCC established a Code of Professional Ethics for Rehabilitation
Counselors which delineates exemplary rehabilitation counseling as being a service that is
client- centered, sensitive to an array of disabilities, vocationally inclusive, encourages a
collaborative and multidisciplinary focus, and is defined within the context of an established
profession.19In addition to the CRC credential, many rehabilitation counselors hold related
credentials such as the certified case manager (CCM), which has a strong focus on medical
case management, or the certified disability management specialist (CDMS) credential, which
emphasizes vocational case management. The latter replaced the certified insurance
rehabilitation specialist (CIRS) credential.

While credentialing has afforded rehabilitation counselors with practice standards and
ethical guidelines for many years, rehabilitation counselor must become aware of the
counselor licensure legislations in their states. Currently, 45 states along with the
District of Columbia have enacted legislations to protect the title and regulate the
professional practice of counseling. Themost common title in counselor licensure bills
has been the Licensed Professional Counselor (LPC); other titles include licensed
mental health counselor and licensed clinical professional counselor. While several
states (e.g., Wisconsin and Illinois) consider the CRC credential in conjunction with
appropriate clinical hours as meeting the licensure requirements, there is a growing
tendency towards standardizing licensure requirements across states. Of particular
importance is the 60-credit degree requirement that has been enacted in 24 states, which
will have significant implications for rehabilitation counselors who graduated from a 48-
credit rehabilitation counselingprogram.

Counselors who work in rehabilitation

A counselor who works in rehabilitation must be a professional with a clear sense of purpose
(Parker & Patterson, 2012; Wright, 1980, 1987). There are several competing, but not necessarily
mutually exclusive, ideas about what roles and functions such counselors should assume. In the
late 1960s, Muthard and Salomone conducted the first systematic investigation of the work
activities of counselors in rehabilitation, then known as rehabilitation counselors (Bolton
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&Jaques, 1978). They found eight major activities that characterize the counselor’s role and
noted a high degree of importance attached to affective counseling, vocational counseling, and
placement duties (Muthard&Salomone, 1978). In this survey, rehabilitation counselors reported
spending the majority of their time in counseling and counseling-related activities just as
counselors in other specialties did. The same appears to be true today, although there is more
paperwork.

In 1970 the U.S. Labor Department listed 12 major functions of rehabilitation counselors, which
are still relevant for counselors who focus their practices on rehabilitation.

1. Personal counseling. This function entails working with clients individually from one or
more theoretical models. It plays a vital part in helping clients make complete social and
emotional adjustments to their circumstances.

2. Case finding. Rehabilitation counselors attempt to make their services known to agencies and
potential clients through promotional and educational materials.

3. Eligibility determination. Rehabilitation counselors determine, through a standard set of

guidelines, whether a potential client meets the criteria for funding.

4. Training. Primary aspects of training involve identifying client skills and purchasing
educational or training resources to help clients enhance them. In some cases, it is necessary to
provide training for clients to make them eligible for employment in a specific area.

5. Provision of restoration. The counselor arranges for needed devices (e.g., artificial limbs or
wheelchairs) and medical services that will make the client eligible for employment and increase
his or her general independence.

6. Support services. These services range from providing medication to offering individual and
group counseling. They help the client develop in personal and interpersonal areas while
receiving training or other services.

7. Job placement. This function involves directly helping the client find employment. Activities
range from supporting clients who initiate a search for work to helping less motivated clients
prepare to exert more initiative.
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8. Planning. The planning process requires the counselor to include the client as an equal. The
plan they work out together should change the client from a recipient of services to an initiator of
services.

9. Evaluation. This function is continuous and self-correcting. The counselor combines

information from all aspects of the client’s life to determine needs and priorities.

10. Agency consultation. The counselor works with agencies and individuals to set up or
coordinate client services, such as job placement or evaluation. Much of the counselor’s work is
done jointly with other professionals.

11. Public relations. The counselor is an advocate for clients and executes this role by informing
community leaders about the nature and scope of rehabilitation services.

12. Follow-along. This function involves the counselor’s constant interaction with agencies and
individuals who are serving the client. It also includes maintaining contact with the clients
themselves to ensure steady progress toward rehabilitation.

The incorporation of CORE into CACREP and the new emphasis in all counseling fields and
settings on ability, disability, and rehabilitation is a step forward in the evolution of the
profession. It means that counseling, like most of its related helping professions, is becoming
more united, broad, and focused in working with individuals, groups, families, and society in a
comprehensive and effective way.

Mental health has been defined by the Surgeon General of the United States as

The successful performance of mental function, resulting in productive activities, fulfilling

relationships with other people, and the ability to adapt to change and to cope with adversity;
from early childhood until later life, mental health is the springboard of thinking and
communication skills, learning, emotional growth, resilience, and self-esteem. (U.S. Department
of Health and Human Services, 1999, p. vii)

While mental health has never received as much attention and funding as physical health, it has
been a major focus within the nation at various times.

The most significant early piece of federal legislation that brought mental health much more on
par with other health services in the United States was the Community Mental Health Centers
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Act of 1963. This act was intended to promote local mental health initiatives. Through it the
mental health counselor movement became full blown. It provided funding for the establishment
of more than 2,000 community mental health centers nationwide. It also made it possible for
local communities to employ mental health professionals from a variety of backgrounds and
focus on mental health education in the form of outreach programs. As time went on, the focus
of mental health centers began to change from one of prevention (the original intent) to one of
treatment. The treatment emphasis was especially highlighted in the late 1970s and early 1980s
as state and federal mental hospitals were deinstitutionalized, and individuals with a variety of
mental problems, some quite severe, were picked up by these centers or left to cope on their own.

Mental health counseling has been defined in many ways during its relatively brief history.
Initially, it was described as a specialized form of counseling performed in noneducational,
community-based, or mental health settings (Seiler & Messina, 1979). Over the years, however,
different views of mental health counseling have evolved, including those that are developmental
(Ivey, 1989); relationship focused (Ginter, 1989); and slanted toward treatment, advocacy, or
personal and environmental coping (Hershenson, Power, & Seligman, 1989). The Council for
Accreditation of Counseling and Related Educational Programs (CACREP, 2016) has developed
a detailed description of this specialty and has established academic coursework, basic
knowledge, and clinical skill requirements for programs in clinical mental health counseling.

How Mental Health Counseling Works

Mental health counseling is a formal, purposeful partnership between a client and a mental health
professional. It's sometimes referred to as clinical mental health counseling; not because it's cold
and dispassionate but because it is based on sound research and uses techniques proven to be
effective.

Counseling is a process of varying lengths during which a mental health counselor and a client
work together to explore problems and develop the skills and mindset needed to transcend
challenges and live a life of emotional health. The length of the counseling process varies
depending on the individual and the mental health disorder or distress. It can continue anywhere
from a few weekly sessions to months or, sometimes, years of occasional sessions.
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People seek counseling for many different things. Counseling is for mental illness as well as for
specific life stresses, such as a toxic workplace with a bullying boss. Counseling happens
individually, in one-on-one sessions with a counselor. Additionally, people can engage in
couples therapy, family therapy, or group therapy.

Presently, clinical mental health counseling “is a master’s level, primarily practice-oriented
profession. It shares a border with professional counseling [and is a part of counseling] in its
conceptual and philosophical perspective that is more educational-developmental-preventive
than clinical remedial” (Pistole & Roberts, 2002, p. 15). Overall, clinical mental health
counseling is a specialty within the field of professional counseling.

Clinical Mental Health Counseling as a Spatiality

Clinical mental health counseling is interdisciplinary in its history, practice settings, skills/
knowledge, and roles performed. This interdisciplinary nature is an asset in generating new ideas
and energy. At the same time, it is a drawback in helping those who identify themselves as
clinical mental health counselors distinguish themselves from some closely related mental health
practitioners (Wilcoxon & Puleo, 1992).

Regardless, many practitioners within the counseling profession use the term mental health
counselor or clinical mental health counselor to describe themselves, and some states, such as
Florida, designate licensed counselors under these titles. As a group, clinical mental health
counselors work with a diverse group of clients, including those who are rape victims, have
eating disorders, experience depression, have family problems, are potentially suicidal, and those
with diagnosable disorders as listed in the DSM. In addition, they consult, educate, and at times
perform administrative duties. Thus, it is crucial that these counselors have a wide range of
knowledge and experience as well as know psychopathology as defined by the Diagnostic and
Statistical Manual (DSM) classifications. This type of background enables them to converse
intelligently with other health professionals and skillfully treat dysfunctional clients (Hinkle,
1994; Newsome & Gladding, 2014; Vacc, Loesch, &Guilbert, 1997).

Clinical mental health counselors have basic counseling skills as well as specialty skills related
to the needs and interests of particular populations or problems. Major duties of counselors in
mental health are assessing and analyzing background and current information on clients,
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diagnosing mental and emotional conditions, exploring possible solutions, and developing
treatment plans. Preventive mental health activities and recognition of the relationship between
physical and mental health are prominent in their work.

As a group, clinical mental health counselors are interested in professional development and
counseling topics related to applied areas of counseling such as marriage and family counseling;
substance abuse/chemical dependency; third-party reimbursement; small-group counseling; grief,
loss, and bereavement; as well as mindfulness and posttraumatic growth, just to name a few
(Chopko& Schwartz, 2009; Prieto, 2011). Such interests are understandable in light of the fact
that most clinical mental health counselors are practitioners and earn a living by offering services
for remuneration.

The American Mental Health Counselor Association (AMHCA, 801 N. Fairfax Street, Suite
304, Alexandria, VA 22314) has initiated a number of task forces and committees over the years
to help its members broaden their horizons and develop practical skills and knowledge. These
task forces cover such areas as business and industry, aging and adult development, treatment of
various disorders, and prevention. Such concentrations are important because they allow clinical
mental health counselors to obtain in-depth knowledge and skills in particular domains.

AMHCA also emphasizes total health and wellness including wellness counseling. This aspect of
clinical mental health counseling is vital because changes made within a community can be
upsetting or cause regressive behaviors if people are unprepared. By providing clients and
communities with health information and support, counselors can prevent more serious problems
(e.g., alcoholism or depression) from occurring. Such an emphasis is unique in many helping
professions, which as a whole tend to be treatment based.

In addition, AMHCA has set up certification standards for counselors to become Certified
Clinical Mental Health Counselors (CCMHC). This procedure initially involved the
establishment of the National Academy of Certified Clinical Mental Health Counselors
(NACCMHC) as an independently incorporated certification group in 1978. In 1993,
NACCMHC merged with the National Board for Certified Counselors (NBCC), and now
professionals who wish to obtain the CCMHC credential must first become national certified
counselors (NCCs).
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Theories and Functions

As indicated previously, clinical mental health counselors are diverse in their interests and the
ways they use theories and techniques in their practices. This diversity is due in part to the varied
settings in which they work and the wide range of functions they have. Thus, some clinical
mental health counselors focus on concepts such as forgiveness (Wade, 2010) and self-care,
while others look at non suicidal self-injury (Trepal, 2010). One theoretical position, existential
theory, has been advocated as “congruent with the essential principles of mental health
counseling” (Bauman & Waldo, 1998, p. 27), but a large number of theories have been used by
practitioners in the field. The selection of theories by clinical mental health counselors depends
on their clients’ needs. Generally, the literature about clinical mental health counseling focuses
on two major issues that have theoretical implications:

a) Prevention and promotion of mental health.

b) Treatment of disorders and dysfunctions.

Both topics are likely to continue attracting attention because they are considered primary roles
of clinical mental health counselors (Sheperis & Sheperis, 2015).

Primary prevention and the promotion of mental health. A primary philosophical emphasis
throughout the history of clinical mental health counseling has been on prevention and
promotion of mental health services. Many clinical mental health counselors are actively
involved in primary prevention types of programs through schools, colleges, churches,
community health centers, and public and private agencies. Primary prevention is characterized
by its “before the fact quality”; it is intentional and “group- or mass-, rather than individually,
oriented” (Baker & Shaw, 1987, p. 2). It may be directly or indirectly implemented, but it is
based on a sound theoretical foundation. For example, the establishment of more than 1,200
suicide and emotional help lines worldwide and on the Net (Internet) to deal with the warning
signs of suicide is a primary prevention approach to dealing with this problem (Befrienders
International, 2007). When successful, primary prevention ultimately results in healthier and
better adjusted individuals and communities.
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Hall and Torres (2002) recommend two primary prevention models appropriate for community-
wide implementation with adolescents. They are Bloom’s (1996) configural model of prevention
and Albee’s incidence formula (Albee &Gullotta, 1997).

Bloom’s configural model of prevention focuses on three dimensions:

 First, counselors need to work to increase individual strengths and decrease individual
limitations.
 Second, they must increase social support (e.g., through parents and peers) and decrease
social stress.
 Finally, address and rectify environmental variables, such as poverty, natural disasters,
and improve community programming for youth.

Albee’s model is equally global in scope and emphasizes that counselors must decrease the
negative effects of biology and stress while simultaneously increasing the positive effects of
adolescents’ coping skills, self-esteem, and supportive systems. Both models require a
willingness by counselors to network with other agencies and individuals. They must invest
considerable time and energy in program construction that may not have an immediate payoff.

One place where primary prevention is emphasized is in the area of suicide (Granello &Juhnke,
2009). In the United States, suicide is “the ninth-ranking cause of death for adults and third for
young people ages 17 and under” (Carney &Hazler, 1998, p. 28). Suicide is also the fifth-leading
cause of death among Canadians (Paulson & Worth, 2002).

When assessing clients for suicide, clinical mental health counselors need to be mindful that
there are various factors that influence the rates and lethality of suicide attempts (Granello,
2010b). For instance, three times as many females as males attempt suicide, but about three times
as many males as females are successful (McWhirter, McWhirter, McWhirter, & McWhirter,
2013). Tragically, the likelihood of suicide for gay and lesbian youth is two to three times higher
than for heterosexual youth. In addition, different ethnic groups are more at risk for suicidal
behavior than others. Native Americans have the highest adolescent suicide rate, and Latino
adolescents have a higher rate of suicide than European American youth (McWhirter et al.,
2013).
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In addition to gender, sexual orientation, and multicultural variables, clinicians need to use
assessment instruments to evaluate more accurately suicidal ideation. One global scale they may
use is the SAD PERSONS scale (Patterson, Dohn, Bird, & Patterson, 1983) for adults or the
Adapted-SAD PERSONS scale (A-SPS) for children (Juhnke, 1996) to determine which
individuals are most likely to be at high risk. The letters in this scale stand for the following:

 Sex (male)
 Age (older clients)
 Depression
 Previous attempt
 Ethanol (alcohol) abuse
 Rational thinking loss
 Social support system lacking (lonely, isolated)
 Organized plan
 No spouse
 Sickness (particularly chronic or terminal illness)

It is the combination of these factors in an interactive process that is likely to yield information
pertinent for clinical mental health counselors to use in prevention. In addition to these specifics,
Granello (2010b) has constructed a list of 12 core process principles that clinicians should keep
in mind when working with a client who is suicidal. These include such factors as recognizing
the uniqueness of each person and realizing that suicide risk assessment is complex, relies on
clinical judgment, should be collaborative with others, and is an ongoing process with all threats
and warning signs being taken seriously. Granello also reminds clinicians that almost all
counselors during their careers will work with a client who makes a suicide attempt. Therefore,
tough questions are called for in assessment, sensitivity to the cultural context is critical, and
documentation of assessment is essential.

Another form of primary prevention is emphasizing healthy development—that is, positive

coping and growth so that individuals are able to deal effectively with crises they may face
(Hershenson, 1992; Juntenun& Schwartz, 2016). “Insofar as counseling derives from a model
based on healthy development, it can reasonably hope to achieve its purpose of promoting
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healthy development in its clients” (Hershenson, 1982, p. 409). Erik Erikson (1963) and
Abraham Maslow (1962) offer basic premises from which clinical mental health counselors can
work. The writings of these theorists were based on observations about human development and
emphasized the promotion of healthy growth and development. The integration of these two
systems of thought yields six personal development trends: survival, growth, communication,
recognition, mastery, and understanding. The first two trends focus on the self, the middle two
on interpersonal functions, and the final two on the accomplishment of tasks. Clinical mental
health counseling is geared toward the improvement of the self in interpersonal relationships and
task performances.

In an important article on healthy personal development, Heath (1980) outlined a comprehensive

model of healthy maturation. He pointed out that research demonstrates that an adolescent’s
psychological maturity is a major predictor of adult mental health and vocational adaptation and
that the degree of adult maturity is related to marital sexual adjustment and vocational
adaptation. Heath then proposed practical general principles that counselors can apply in
promoting client development. Four are listed here (Heath, 1980, p. 395):

 “Encourage the anticipatory rehearsal of new adaptations,” such as those that deal
with jobs and intimate relationships.
 “Require constant externalization of what is learned and its correction by action.”
In essence, Heath believes practice makes perfect in the accomplishment of all human
tasks. Learning is accomplished through feedback.
 “Allow a person to experience the consequences of his or her decisions and acts.”
Heath agrees with Alfred Adler on this idea. He notes that inappropriate or excessive
rewards may have an unhealthy effect on a person’s development.
 “Appreciate and affirm strengths.” Reinforcement, according to behaviorist principles,
is crucial to new learning. Heath agrees and says that the acknowledgment and
acceptance of people’s strengths can bolster self-confidence and help them take the risks
necessary for new learning.

An overall emphasis in clinical mental health prevention related to health is on wellness or

positive wellness (health-related activities that are both preventive and remedial and have a
therapeutic value to individuals who practice them consistently) (Edlin&Golanty, 2016).
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Wellness strategies for counselors include maintaining physical health (e.g., fitness, nutrition,
mindfulness), emotional health (e.g., self-reflection, self-awareness, expressing emotions),
cognitive wellness (e.g., working collaboratively with clients, celebrating personal and
professional achievements, continuing education), and interpersonal relationships (e.g.,
friends/family, personal counseling, consultation, supervision) (Venart, Vassos, & Pitcher-Heft,
2007). Activities associated with these strategies include eating natural foods, taking vitamins,
going to health spas, meditating, participating in regular exercise, and exploring a variety of
humanistic and transpersonal approaches to helping (Granello, 2013; O’Donnell, 1988). For a
person to be a “whole, healthy, functioning organism,” he or she must evaluate many factors and
aspects of life. These include the “physical, psychological, intellectual, social, emotional, and
environmental processes” (Carlson & Ardell, 1988, p. 383). Thus, the concept Eco Wellness (the
relationship of a person to nature and environment) is a major part of wellness (Reese & Myers,
2012).

Health is multidimensional—physical, mental, emotional, cognitive, interpersonal, and so on.

The most extensive evidence-based work in the area of wellness has been conducted by Myers
and Sweeney (e.g., 2008) and their associates. They have developed two instruments to measure
wellness:

 The Wheel of Wellness and

 The Indivisible Self-models.

Wheel of Wellness is spirituality, the most important characteristic of well-being. It includes a

sense of meaning and purpose in life that is very much in line with Alfred Adler’s theoretical
emphasis, which is the basis for this model. Radiating from the center of the wheel are 12 spokes
in the life task of self-direction: sense of worth, sense of control, realistic beliefs, emotional
awareness and coping, sense of humor, nutrition, exercise, self-care, problem-solving and
creativity, stress management, gender identity, and cultural identity.

The Indivisible Self-model is empirical, as opposed to hypothetical, like the Wheel of Wellness.
It is interactive and composed of the creative self, the coping self, the social self, the essential
self, and the physical self. The Indivisible Self is ecological as well, “with four contexts
 19

presented as integral to individual wellness: local, instructional, global, and chronometrical” (p.
485).

Secondary and tertiary prevention. In addition to primary prevention, clinical mental health
counselors concentrate on secondary prevention (controlling mental health problems that have
already surfaced but are not severe) and tertiary prevention (controlling serious mental health
problems to keep them from becoming chronic or life threatening). In such cases (in contrast to
primary prevention), clinical mental health counselors assess client functioning and then, if
appropriate, use theories and techniques developed by major theorists such as Rogers, Ellis,
Skinner, and Glasser to treat symptoms and core conditions.

Clinical mental health counselors who work in treatment face a number of challenges. One is
responding adequately to the number of people who need and seek mental health services. The
nation’s mental health providers such as counselors, psychiatrists, psychologists, and social
workers cannot adequately deal with everyone who needs treatment services for minor or major
disorders. Even if the treatment of clients were the only activity in which these professionals
were engaged, they still would not be able to take care of all those in need (Lichtenberg, 1986;
Meehl, 1973). For example, an estimated 7.5 million children, or 12% of the residents of the
United States, “under 18 years of age have a diagnosable mental disorder, and nearly half of
these are severely handicapped by their disabilities. The population of children with serious
emotional and behavioral problems has been growing dramatically, concomitant with the growth
of such social problems as poverty, homelessness, and substance abuse” (Collins & Collins,
1994, p. 239).

Another challenge for clinicians in mental health counseling is the trend in inpatient psychiatric
hospitals to shorten the length of stays for severely disturbed clients. This trend is known as
deinstitutionalization. These shortened stays mean more disturbed individuals are either not
receiving the treatment they need or being seen in outpatient facilities, where many clinical
mental health counselors work and are often restricted by managed care regulations.

A survey of articles in the Journal of Mental Health Counseling in the early 1990s revealed that
clinical mental health counselors have a stronger tendency to deal with treatment as a major
emphasis of clinical mental health counseling (Kiselica& Look, 1993). The situation has changed
little since, except for the increased amounts of paperwork and regulations brought on by
 20

managed care companies and government regulations such as HIPAA. In this respect, clinical
mental health counseling is more like other helping disciplines, such as psychology, social work,
and psychiatric nursing (Hansen, 1998; Hershenson& Berger, 2001; Waldo, Horswill, &
Brotherton, 1993). Some of the areas clinical mental health counselors focus on in treatment are
general and specific life-span disorders, such as grief and loss (Prieto, 2011), mild depression
(Kolenc, Hartley, & Murdock, 1990), self-injury (Trepal, 2010), smoking cessation (Pinto &
Morrell, 1988), forgiveness (Wade, 2010), obsessive-compulsive behavior (Dattilio, 1993),
trauma and resilience (Goodman & West-Olatunji, 2008), and at-risk youth (Hill, 2007).

Clinical mental health counselors assess and treat disorders using the Diagnostic and Statistical
Manual (DSM). Some deal with severe mental disorders (Perham &Accordino, 2007), whereas
others specialize in working with either less severely disturbed persons or specific populations
and the disorders that impact these groups most. Regardless, individuals who are diagnosed with
mental disorders are among the most stigmatized, marginalized, and disadvantaged in society.
That is partially because the DSM’s perspective is “narrow, biased, deficit based, and
pathologizing” (Goodman, 2015, p. 285). In order to get a feel for what it is like to be diagnosed
with a disorder or to work with someone who does, novice counselors should view films such as
Three Faces of Eve and A Beautiful Mind.

Counselors can work to mitigate the stigma of mental disorders in three ways: protest,
education, and contact (Overton & Medina, 2008). Protest is an active attempt by a group of
people to suppress a stereotype such as all individuals with a mental disorder are dangerous.
Protests can come in the way of rallies or marches as well as visitations to legislative bodies. The
result can be positive and change local public opinion. Protests can backfire too since there are
those in society who have different views and may counterprotest. Education is a means of
conveying factual information about specific populations. It often changes beliefs but not
behaviors. Information distributed by mental health associations and other advocacy groups
promoting positive mental health is educational in nature and should be filled with examples.
Contact, on the other hand—personal interaction with someone from a stigmatized group—does
seem effective in changing both beliefs and behaviors. Increasing education and challenging
people in community settings to have contact with those less fortunate than themselves can often
lead to an increase in understanding and actions. Contact with those who are living with mental
 21

disorders is essential. Such exposure helps to humanize a concept and often leads to the
development of higher levels of cognitive complexity in individuals who have such interactions.
Thus, the behavioral and cognitive component of understanding come together to increase
empathy as well as the reality that textbook descriptions of disorders are not generally what a
person sees when working with another human being who has a diagnosis.

Two general Clinical disorders: Depression and Anxiety

Depression seems to be especially rampant, having increased to epidemic proportions with

“roughly 10% to 25% of the population” experiencing “some form of depression” and with
depression being “10 times as prevalent now as it was in 1960!” (Paradise & Kirby, 2005, p.
116). In addition, depression “may be the most common disorder of mental health workers
themselves … with research suggesting that from one third to more than 60% of mental health
professionals” report “a significant episode of depression within the previous year” (p. 116).

Mental health counselors need to continually educate themselves on the latest treatments of
depression including those that have a proven psychological track record, such as cognitive–
behavioral counseling and mindfulness methods, those that may be more physiologically based,
such as exercise, and those that may be more societal based, such as the building of friendships
and connectedness in families. This latter method of promoting friendships and family
connections is especially powerful with adolescents (Baskin, Quintana, Slaten, 2014). It has
usually been found that a combination of “talk therapy,” medication, and socialization with
others works best in treating individuals who suffer from this malady. However, mental health
counselors need to keep in mind that there are various forms of depression, and acute depression
differs from chronic depression just as depression resulting from the loss of a loved one differs
significantly from depression that is pervasive due to a chemical imbalance in the brain.

Anxiety affects 40 million adults or 18 percent of the adult population. The disorder has both a
genetic and a behavioral component. Anxiety disorders take on a number of forms, and
generalized anxiety (characterized by at least 6 months of persistent and excessive anxiety,
worry), social anxiety (characterized by emotional discomfort or apprehension over social
situations that require interaction with others), and panic disorder (intense fear, usually
accompanied by physical symptoms, such as heart palpitations, sweating, or dizziness, that
something bad will happen that is unexpected) are among the most common (Shallcross, 2009a).
 22

As with depression, there are a number of proven treatments that help clients deal with anxiety,
such as those that are cognitive–behavioral based like systematic desensitization and exposure
therapies. On average counseling appears to be as effective as medication alone for anxiety and
may have the added advantage of providing longer-term relief with fewer side effects (Erford,
Kress, Giugere, Cieri, & Erford, 2015). However, medications may also be needed and
prescribed in dealing with anxiety, and like depression, anxiety disorders in such cases are best
treated with a combination of “talk therapy” and prescriptive medicines. Since anxiety disorders
differ from mild to severe, treatment methods must be tailored to clients.

Regardless of the exact figures on populations affected, depression and anxiety are common in
society for a number of reasons, many of which are featured nightly on the evening news or talk
radio. Mental health counselors, like other counselors, will find themselves working with
individuals who manifest these symptoms regardless of their clinical setting. The good news, as
mentioned earlier, is that there are a number of treatments for both depression and anxiety. All
seem to work well in the treatment (i.e., recovery) and prevention of these maladies (Dixon,
2000; Gladding, 2015a; Paradise & Kirby, 2005).

Trauma and Hopelessness

In addition to treating depression and anxiety disorders, clinical mental health counselors, like
many counselors in other settings, are called on to work with individuals who have suffered
trauma and may feel hopeless. It is estimated that approximately two-thirds of individuals in the
United States will suffer a traumatic event in their lifetime and that these events are at the root of
many mental health problems (Goodman, 2015). Trauma, especially traumatic brain injury
(TBI), is especially prevalent in many members of the military. Thus, knowing about different
types of trauma and how to address it, particularly working in a team of helping professionals, is
important.

There are several models for working with clients who have been affected by trauma, but two
that are most prominent with nonmedical traumas are the crisis intervention model and the
continuing-therapy model (Paulson & Worth, 2002). “Both models stress the significance of a
positive therapeutic relationship and the understanding and validation of client’s feelings” (p.
87), which may be intense. They emphasize the importance of helping those who have gone
through trauma to develop self-awareness, construct a new identity, and deal with loss. The focus
 23

is to restore equilibrium to clients’ biopsychosocial functioning (i.e., the combination of

biological, psychological, and social factors that make up and influence how a person operates
within a society) with the realization that many people will need long-term therapeutic
interventions and that healing from the aftereffects of a flood, tornado, hurricane, fire, or other
natural or manmade disaster takes time as well as work. Whereas both approaches are effective,
the continuing-therapy model is more advantageous because it provides a lengthier time frame
for counselor–client interactions.

In addition to these two models, counselors can also help those who have a sense of hopelessness
from a traumatic event create meaning through the use of an existential-constructivist framework
(Rogers, 2001). This theoretical approach delves into an “increased understanding of …
individuals from a phenomenological meaning perspective” (p. 16). It requires the counselor and
client to commit to long-term therapeutic work and deal with the community and others as well
as focus on intrapersonal thoughts and feelings.

Employment of clinical mental health counselors

As a group, clinical mental health counselors work in a variety of settings, including mental
health centers, community agencies, psychiatric hospitals, health maintenance organizations
(HMOs), health and wellness promotion programs (HWPs), geriatric centers, crisis control
agencies, family services, and child guidance clinics. They often work closely with other helping
professionals, such as psychiatrists, psychologists, clinical social workers, psychiatric nurses,
and other counseling specialists to become part of a team effort.

One place where clinical mental health counselors are being hired in increasing numbers is
employee assistance programs (EAPs) (Newsome & Gladding, 2014). These programs are found
in many businesses and institutions across the United States. Their purpose is to work with
employees in preventive and remedial ways in order to help them avoid or work through
problems that might detrimentally affect their on-the-job behavior. To be effective, EAP
counselors set up programs that deal with a variety of subjects that employees have an interest in,
such as wellness or retirement. They invite outside experts to make presentations at convenient
times and arrange for follow-up material or input if needed. EAP counselors also offer short-term
counseling services to employees who may be experiencing difficulties. These services are
usually time limited (e.g., three sessions). However, as experts in community resources, EAP
 24

counselors are able to make referrals to mental health professionals who can offer employees
more expertise. As an overall rule, large companies and institutions will offer EAP services on
their premises (i.e., in-house), whereas smaller operations will usually rely on EAP counselors
who serve a number of companies and institutions (i.e., outsource).

Another place where clinical mental health counselors may be employed is with crisis-oriented
organizations, such as the Red Cross, Salvation Army, or local emergency telephone and walk-in
counseling centers. In crisis situations, respondents must take care of a multitude of needs
ranging from physical to mental health. Thus, local communities, and even international groups,
hire counselors and other mental health professionals who can offer needed counseling and
supportive services to victims of disasters whether natural or human-made. Individuals who
work in these situations may have jobs that differ from the norm in regard to hours and activities.
They also have above-average excitement and challenges in the work they perform.

Clinical mental health counselors are also found in settings where many other helping specialists
work. For example, counselors with this background may be employed in substance abuse,
hospice, child guidance clinics, wellness centers, colleges, hospitals, and private practice. The
reason they are hired and retained in so many settings is their solid training in CACREP required
counseling areas and their versatility in regard to helping people with a wide variety of
difficulties or concerns. With experience, clinical mental health counselors may obtain
specialized training in a theoretical or treatment modality. They may stay generalists in mental
health, too. There are advantages as well as limitations for clinical mental health counselors
depending on their degree of specialization.

Private practice as a specialty

Private practice counselors have less of a formalized history than mental health counseling.
There have been such professionals from various backgrounds since the beginning of counseling.
Private practitioners aspire to work for themselves in an individual or group practice unaffiliated
with an agency. Before insurance, third-party payments, managed care, and HIPAA, the
professional lives of such individuals were less complicated. They were like physicians in
working on a fee-for-service basis (i.e., paying for services separately as opposed to paying for
 25

services in an integrative way). That arrangement changed dramatically in the 1980s as fee-for-
service arrangements began to disappear.

Despite changes in the ways clinicians are now reimbursed for service, private practice is still
popular (Harrington, 2013; Shallcross, 2011a). When many students first enroll in a counseling
program, they aspire to set up a private practice. Often counselors conceptualize that a private
practice setting will give them more control over their lives, a choice of working hours and
location, ability to work from a preferred theoretical approach, and more financial rewards.
Indeed, a private practice can be a wonderful experience. However, it has a downside as well. It
usually takes a great deal of work to begin such a practice unless a professional buys, or is
invited into, an already established practice. Furthermore, there is the matter of financial
vulnerability and an inconsistency in income over the course of a year.

Difficulties in Setting Up a Private Practice:

To be successful as a private practitioner, counselors need a number of abilities beyond clinical

expertise. Among the most salient of these abilities, they
 must be able to balance business skills, such as marketing, billing, and hiring a secretary,
with those of counseling or else find a competent business manager (Colburn, 2013);
 must be patient, persistent, and prepared for the time it takes to build up a clientele that is
sufficient to make a living;
 must network and build up an outside clinical and ethical support system in a way not as
necessary in agency work, where one is often surrounded by colleagues who can supply
needed information on treatment, supervision, or referrals to appropriate specialists
(Brennan, 2013);
 must become technologically savvy in developing a website, using e-mail, iPhones, and
other technology to both make themselves known and to keep up with clients and referrals;
 must overcome or avoid the use of restrictive covenants or noncompetitive agreements that
some agencies put in their contracts with counselors that prohibit them from setting up a
private practice within a certain geographical area or within a certain time period after
leaving the agency (Wyatt, Daniels, & White, 2000);
 26

 must invest time and hard work in “pull marketing” relationships (i.e., making themselves
attractive by generating referrals through offering needed services to people in groups [such
as singles, the divorced, or the widowed]) and meeting other community professionals
regularly in order to learn about them and to introduce themselves (Crodzki, 2002);
 must find a way to make sure emergency situations and the unexpected crisis some clients
have are covered when out of town or out of the office; and
 must be willing to donate services and participate in endeavors for the public good in order to
build up a reputation and a practice, for as Allen Ivey remarked: “There is just a very small
window for private practitioners to make big money” (Littrell, 2001, p. 117).

Advantages in Setting Up a Private Practice:

There are opportunities for counselors to enter private practice and succeed. Indeed, mental
health agency administrators view “private practitioners … as the greatest competitors for
insured clients” (Wyatt etal., 2000, p. 19). Among the advantages private practitioners have are
the following:
 A growing dissatisfaction among consumers with mental health managed care. In such an
environment, consumers are most likely to begin paying directly for services when they can
afford it and not go through a managed care arrangement. Such an arrangement may benefit
counselors in private practice and portions of the public.
 A chance for counselors to develop a niche or a specialty and become known in their
communities as professionals who provide quality service in a distinct area and in the process
gain excellent reputations as clinicians (Paterson, 2008).
 An opportunity for counselors to set up their office hours in a location and for times most
convenient for them (Harrington, 2013).
 A chance for counselors to branch out in treatment services, such as coaching, consulting, or
working with special populations such as older adults, especially if they live in large urban
areas where there are abundant numbers of clients with business and other specific problems
that are not necessarily traditionally counseling (Colburn, 2013).
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 An opportunity to be entrepreneurial, using the enterprising aspect of their personality to

advertise their services, and artistic using the creative side of their personality to develop
products, such as books and videos. Clinicians usually cannot use these aspects of themselves
as fully in agency settings because of other demands (Shallcross, 2011a).

Reference
 Peterson, T. (2017, October 23). Mental Health Counseling: How it Works, Benefits,
HealthyPlace. Retrieved on 2020, November 13 from
https://www.healthyplace.com/other-info/mental-illness-overview/mental-health-
counseling-how-it-works-benefits
 Counseling: A Comprehensive profession, Samuel T. Gladding