Fear: False Evidence Appearing Real

That is my favorite definition of fear, as it is quite accurate. Sure, there are some fears that are irrational and not quelled by seeking information, for I know firsthand the entanglement of irrationality. Some of the more common fears include: the dark, dying, being alone, heights, spiders, etc. However, my biggest fear is not amongst these, as I see best in the dark, know that everyone dies, thrive on being alone, remain calm when my feet are far from the ground and well, spiders are cool if they stay outside.

As I sit here in a hotel room, awaiting an event I have trained for over the past year, I am full of reflection, anxiety, nervousness, excitement…oh, and fear too. Not that many years ago, I sat alone in a hotel room, but that experience was quite different, yet the same descriptions of feelings were present. Then, I had attempted to overdose (on purpose), with a note in my pocket for whoever was the person unlucky enough to find my body. Clearly, my attempt was unsuccessful. A fact for which I am grateful.

Fast-forward a couple of years, to where I am now…in a hotel room, clothes hung up for the events of the following day, a mini-fridge full of Greek yogurt, skim milk, cottage cheese, G2 and Superfood with spirulina. Oh, and some bananas, a couple gallons of water and some gummy bears that just jumped in my bag (sneaky little guys).

Both of these events involved a possibility of death; the overdose attempt and the “death waiver” I had to sign to participate in tomorrow’s event. I find it interesting that two events, on the polar opposite sides of the spectrum, have so much in common. Tonight’s reflection is focused on how far I have come (and how far I still have left to go), the changes I have made in my life and things I can focus on changing in the future. I can feel the heart palpitations associated with anxiety, for the events of tomorrow are like nothing I have ever attempted in the past.

Most of all…I am scared. Scared of failing; failing myself and my team. We shall see.

And, just in case there are some readers who don't know what event I will be participating in tomorrow... here is the website

Never Forget (As If I Could)

      That morning. The sun was out, shining over the harbor. Planes were taking off from Logan and passing over Boston’s North End. I donned my blue uniform, as I had done all those years, not knowing what was set to happen later that day. While working in Aux I of a 270’ cutter, one of my shipmates had lowered down the watertight hatch, dogging all the corners, the change in atmospheric pressure danced upon my eardrums. Wondering what was happening, I opened the center of the hatch, poking my head through. I walked out to the messdeck, where there was an image, one of which I will never forget, playing on the television. The whole ship seemed silent, without the usual banter between shipmates. 

      My crew was ordered to return to our shop on base where many had tried to call family members, only to find the cell phone towers were overwhelmed. The look upon the faces of those who surrounded me was one of disbelief. There wasn’t anything that covered this in our Bluejacket manual. On the walk back to our shop, I decided I would tell my chief that if they needed anyone, to please send me. I didn’t care where, when or for how long, I wanted to go. Knowing that one of the planes had flown right over our base seemed to irk and rile me, fueling my desire to do something.

      The next day I was in New York. There was still an enormous amount of confusion as to what happened, who was responsible and what needed to be done. We had a makeshift base set up, the Red Cross was dispatched to provide food (in addition to tasty MRE packs) and we had brought our portable tool shop. We were ready…for what, we didn’t know, but we were ready.

      What followed was a month of long nights, seeing things that I didn’t want to see and a massive intake of alcohol to numb the feelings. That event changed our lives. When I was stationed on the East Coast, I would make a trip to NY for each anniversary. When I transferred, I would still watch the coverage on television, however, a couple years ago I found myself getting mad and crying, so I stopped watching. 

Instead of watching, I plan on doing. 

      Later on this month, I am participating in a Tough Mudder (http://toughmudder.com), an event I have been training for over the course of the past year. Proceeds from the event go towards an awesome cause that brings tears to my eyes…The Wounded Warrior Project (http://www.woundedwarriorproject.org). I also have completed my BS degree and have started on my MS in Counseling so I can continue to help those who have been affected by some of the events that also affect myself. 

My cause, my mission, my passion…

From hopeless to hopeful: Assisting veterans in housing, medical and mental health needs

Abstract

With the changing economy, more individuals are finding themselves unable to make ends meet, on the brink of becoming homeless. The United States Veterans Affairs (VA) have identified homelessness amongst veterans as a growing problem, often compounded by the presence of substance abuse and/or mental health disorders, creating a comorbidity factor, which requires special attention. The VA, in partnership with the current government administration, aims to end veteran homelessness by 2015, which is quite a lofty goal. Since the Homeless Veterans Initiative came to fruition in 2009, over $60 million has gone towards assisting 22,000 veterans and family members (http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2355). 


      By adhering to The Soldier’s Motto, “I will never leave a fallen comrade” the homeless veteran population may be something to add to the history books. The program proposed in the following paper will attempt to address the unique needs of homeless veterans, including mental health, substance abuse, vocational training and an evaluation of individual’s benefits in partnership with the VA. 

Community needs

Addressing the unique needs of a community requires a thorough understanding of the culture involved, the strengths and shortcomings of programs that are already in place, and how to provide mental health counseling in a manner that is both cost and time effective. Much can be gleaned by observation, surveys, and interviewing both providers and those who use the services. Finding a right fit for the community is essential to increase the likelihood of individuals actually seeking out and using a new program. 

A survey conducted on a cold night in January in 2011 revealed that there were 67,495 homeless veterans on the street, with almost 150,000 who had spent at least one night in an emergency shelter program during the previous year. The state of Oregon has a large homeless population, with 1,425 (or 8%) comprised of veterans (http://cms.oregon.gov/odva/info/Pages/stats.aspx). 

      Homelessness, defined as a lack of a fixed and regular nighttime residence, is associated with a higher incidence of both poor mental and physical health (Gordon, Haas, Luther, Hilton and Goldstein, 2010). There are current programs in place that aim to address the homeless veteran problem, but with the assistance of grants from the VA, more programs can be implemented that can better address the needs of this unique population. 

Services needed

Comorbidity of psychiatric and medical disorders amongst the veteran community is a common occurrence, with addiction and generalized illness (comprised of eye problems, hypertension, COPD, liver disease and gastrointestinal problems) indicating the highest correlation (Goldstein, Luther, Haas, Gordon and Appelt, 2009). Thus, a treatment program that addresses substance abuse and mental health counseling, in conjunction with medication management, housing and vocational training may prove beneficial to the individual seeking assistance. Grants from the government, which go towards helping non-profit organizations in providing services for low income veterans can help to offset housing and operating costs, thus reducing the monetary burden. 

Currently a couple of initiatives address the need to connect homeless veterans with needed psychiatric services, including domiciliary care for homeless veterans (DCHV) and homeless chronically mentally ill (HCMI). However, those who have a need for such services already outweigh the resources available, making alternatives a necessity (Stovall, Flaherty, Bowden and Schoeny, 1997). 

Goals and objectives

Measurable goals, both terminal and ultimate are important in considering the implementation of a new program. Ensuring the goals are feasible, viable and pragmatic are essential to creating realistic benchmarks (Milstein and Wetterhall, 2000). Focusing on evidence-based practices may shorten the evaluation period due to the proven record of accomplishment during prior therapeutic interventions (Calley, 2009). The initial goals for the proposed program are to address acute health and mental health problems, resource-related problems (housing, employment and hygiene), and public perception problems (rejection, dehumanization and community fear of veterans), which were identified as the main contributing factors to the problems experienced by homeless veterans (Applewhite, 1997). Long-term goals of the program include treating any substance abuse or other issues documented during the initial intake, vocational training and employment opportunities, which can help to facilitate self-sufficiency. 

The proposed program aims to coincide with the Six Pillars of the Homeless Initiative, as set forth by the VA, which include community partnership, income and benefit analysis, housing and support services, outreach and education, prevention of becoming homeless and treatment of medical and psychiatric needs (http://www.va.gov/HOMELESS/about_the_initiative.asp). By blending programs it will be easier to implement tactics used successfully in the past, thus reducing the amount of time needed for program research.

Program design

Prior to acceptance into the program, clients would be screened by mental health counselors regarding their present level of assistance required, the presence of any comorbidity factors (primarily those involving drug and/or alcohol abuse) and their current living situation (threat of becoming homeless, homeless, living with friends, etc.). The screening is an important aspect, as certain comorbidity relationships have an impact on behavior and functioning (Goldstein, Luther, Jacoby, Haas and Gordon, 2008), which may affect the other residents in the program. Another consideration to keep in mind during screening is that the facility will be a clean and sober living situation, which residents will have to agree to and abide by in order to remain in the program.

The ideal facility would be one of many vacant apartment buildings located within the county, purchased with funds provided by government grants. If the units are 1-2 bedrooms, there should be at least 10-12, more if they are studio apartments. Some considerations regarding facility amenities would include handicap access and proximity to loud noise generators, which may cause undue stress upon residents. 

      One unit would be staffed 24-hours a day and designated for treatment, including counseling, group meetings and medication management. Vocational programs may supplement staffing needs by training residents to fill the needs of the program, thus not only help to lower the operating costs, but also promote a positive self-image and foster resiliency within the clients. However, a licensed counselor and direct care providers would still be required onsite, as these positions would be solely support and clerical services.

      Counselors working within the program should be familiar with the unique needs of both the military and homeless communities, and use a holistic approach when interacting with clients. A bio-psycho-social-spiritual approach is often effective in drug and alcohol rehabilitation settings, as it allows for more flexibility in therapeutic interventions. The use of motivational interviewing, which is a client centered approach with a focus on strengthening intrinsic motivation has also shown to be beneficial in improving program interaction, retention and a reduction in relapse incidents (Wain, Wilbourne, Harris, Pierson, Teleki, Burling and Lovett, 2011). A focus on psychosocial rehabilitation would also prove beneficial, as the main philosophy includes some commonalities to the Six Pillars highlighted earlier, consisting of an emphasis on teaching essential skills of community living: vocational, social/recreational, residential and educational (Juvva and Newhill, 2011).

      Even the well-educated and seasoned counselor may find himself or herself amongst unfamiliar territory, as clients are individuals, and that brings a collection of unique experiences. Having an effective consultation and referral program is essential to success, for both the client and counselor alike. Some resources to consider include VA trained staff, religious or clergy members, parole or probation department specialists and those familiar with evaluating military benefits including disability payments.

      Working with local agencies would also provide a way for the clients to engage in their recovery and reintegration as productive members of society. Creating a partnership between the program and vocational training centers, such as Goodwill, Salvation Army and Habitat for Humanity will assist the clients in earning both monetary compensation and employment skills that they can use after graduation from the program. 

Evaluation 

      An important part of any program is a reevaluation after a period, to analyze the strengths and weaknesses present and to address such findings. The key aspects to evaluate would be cost-effectiveness, relapse rate, program retention, improvement (or decline) in mental health conditions and positive contributions to the program and the surrounding community by the clients. A way to address a possible cost issue is to apply the disability or SSI payments of the residents to the rent, recruit graduate students for the direct care staff, conduct fundraisers or apply for additional grants.

      Allowing for flexibility in treatment delivery approaches to fit the client may assist in increased sobriety and program retention; however, if it becomes troublesome or ineffective, a reevaluation of methods is warranted. An examination of program length is important, as some clients may be staying after they have completed treatment, thus taking a spot that could be filled by another homeless veteran. However, keeping with the mission statement of “I will never leave a fallen comrade,” the program will not abandon clients, but rather refer them to other programs that will better suit the needs of the veteran.

Reporting outcomes

Public disclosure, transparency and informing the stakeholders of the strengths and weaknesses of programs can help to ensure accurate information is disseminated, rather than speculation. Such avenues include town hall forums, VA meetings, ballot measures, articles published in peer-reviewed journals and letting the positive results speak for themselves.

Conclusion

While veterans are the minority amongst the homeless population in Oregon, the fact that there is even one without consistent shelter is a concern. The influx of returning soldiers from wars and conflicts overseas may contribute to a growing need of the services proposed by the aforementioned program. By offering a one-stop veteran assistance program, combining shelter, mental health, substance abuse and veteran benefit analysis, the incidence of homeless veterans may decrease, thus showing the respect these men and women deserve.

*References available upon request

Roles and approaches within clinical mental health counseling

Abstract

The definition of supervision varies within the context in which it is applied, however, within the counseling profession, one seems to stand out as the most widely accepted. According to Bernard and Goodyear (2004), supervision is, “…an intervention provided by a more senior member of a profession to a more junior member or members of that same profession. This relationship is evaluative, extends over time, and has the simultaneous purposes of enhancing the professional functioning of the more junior person(s), monitoring the quality of professional services offered to the clients, she, he or they see, and serving as a gatekeeper for those who are to enter the particular profession.”



While the presented definition does appear to be applicable, it is just the groundwork for what supervision entails, as it is multifaceted, needs to be tailored to the situation and personnel involved, including the client, supervisee and the supervisor. The definition also does not address the different models, theories and methods involved, allowing much to be interpreted by those involved in such a relationship. The following paper will provide a brief overview of supervision, models and theories used within clinical mental health counseling. 

Roles and functions

     Supervision within the counseling is one of the more important and prominent part of one’s position as a member of the mental health community. However, although supervision is conducted by at least two thirds of counseling psychologists, few have received thorough training in the application of effective supervisory skills (Milne and Oliver, 2000). By requiring supervision but not providing training, the experience is unique as it is influenced by the one providing the guidance, which is influenced those who had supervised them early in their careers. 

     However, the American Psychological Association’s (APA) Office of Accreditation observed such a gap and in 1996, added supervision as one of the skills to be included in accredited programs at the doctoral and internship levels, thus addressing the need to have formal education in supervision (Peake, Nussbaum and Tindell, 2002). According to the APA, supervision covers a vast and diverse collection of responsibilities, including but not limited to: monitoring, evaluating, instructing, advising, modeling, consulting, supporting, foster autonomy within the supervisee and a responsibility to the patient, profession, system and society. Supervision also addresses legal and ethical issues that may arise, thus further emphasizing the importance of effective training within the mental health profession (www.apa.org). 

     Supervision is not complete at the end of one’s internship, as an interaction between junior and senior counselors can help to provide insight on new therapeutic interventions, different perspectives on a situation and work as a supportive environment in which to voice concerns that may arise. Supervision isn’t just a requirement among American counselors, as members of the Humanistic and Integrative section of the UK Council of Psychotherapy have to apply for membership every five years and state what style and source of supervision they are currently engaged in within their practice (www.hipcollege.co.uk). 

Models within supervision

There are several different models of supervision found within the field of counseling, including individual, group and triadic. Each has their strengths and weaknesses, including within the application and reception by the supervisee. Individual, one-on-one supervision is the most costly in resources, as time is available in limited quantities when there are several students that require supervision and only a few senior counselors to provide the needed individual interaction. However, the approach is more effective when providing feedback regarding casework and planning for future sessions (Milne and Oliver, 2000). Group supervision usually involves a small number of supervisees, which may help to foster a cohort effect, thus the students are able to teach each other through their experiences, with a senior member overlooking and guiding the process.

     The Council for Accreditation of Counseling and Related Educational Programs (CACREP) approved a third method of supervision in 2001, which is the triadic method. The premise behind the triadic approach is a working tutorial relationship between a supervisor and two counseling students, involving all three members in an open and supportive communication atmosphere (Lawson, Hein and Getz, 2009).


     Within the different models, there are is a plethora of methods used to help to facilitate effective supervision. Both audio and visual recordings of sessions conducted by the student can serve as an accurate measure of providing feedback, as the supervisor is able to see and hear what occurred within the session. Having the video of the session may also provide insight to the importance of non-verbal communication between the client and the student. However, knowing that one is being recorded may alter the behavior, of both student and client. 

     Another less obtrusive method of supervision is the bug-in-the-ear or eye, which is a method approved by CACREP, involves either a small receiver to be placed inside the supervisee’s ear in which the supervisor provides support and feedback during a session. With the bug-in-the-eye technique, the supervisor monitors the session and provides written guidance via a monitor that is behind the client. Both of these methods are effective, as they allow the supervisor to provide real-time feedback, assisting when the student may run into a challenging moment. However, they also serve as a possible distraction and added source of stress for the supervisee. Methods are more likely to be effective and well received when tailored to the individuals involved in the therapeutic relationship, which includes the supervisor, supervisee and the client.

     Just as there are different models and methods in providing effective supervision, there are a variety of theories used in mental health settings, each with strengths and weaknesses associated with their unique approaches and views. Some are psychotherapy-based in their approach to supervision, which includes psychodynamic, person-centered, experiential, psychodrama, cognitive, cognitive behavioral, multimodal, solution-focused and narrative (Pearson, 2006). Another approach is the Littrell, Lee-Borden and Lorenz Model of supervision, characterized as a developmental approach since it focuses on the supervisor’s transitional role as the supervisee passes through four sequential stage. The stages are supervisor as teacher, establishing a relationship and setting goals; continue with scaffolding of supervisee, providing feedback in perceived skill deficits; collaborative relationship between supervisor and supervisee; and finally a graduation of the supervisor to a consultant role, allowing the supervisees to take greater responsibility (Nelson, Johnson and Thorngren, 2000).

Intern expectations of supervision

     Supervision is an important aspect in the continued learning environment, providing support, feedback and establishing a supportive atmosphere in which a new counselor can thrive. Forming a positive bond with one’s supervisor during internship and as a new clinical mental health counselor can help to facilitate effective communication, which can help to enhance the experience. The type of supervision can vary depending on the work environment, clients treated, financial resources and even the culture within the community.  

     Some individuals may not feel as comfortable in one-on-one supervision and may prefer the small group or triadic models, especially if the relationship between supervisee and supervisor is not welcoming or appears cold and impersonal. As one who desires to work within the military community as a mental health counselor, it is more likely that the type of supervision that will be present will be of the group variety, due mainly to cost constraints and the availability of supervisors. In the military setting, much of the therapy is of limited duration and would fall within the solution-focused aspect of the psychotherapy-based approach. Supervisors who have specialized training in the same field would be beneficial as well, since clients who are seeking a marriage and family counselor may differ from those who are seeking a trauma therapist.


Conclusion

     Supervision, like the field of counseling itself, is quite varied. Depending on a variety of methods, models and theories to assist in developing a well-rounded counselor, able to effectively help clients during the span of their career. Developing a supportive atmosphere that allows for fostering confidence and an open dialogue between the supervisor and supervisee is tantamount to a positive and successful outcome, which is important for all parties involved. The approach must be holistic in nature, as individuals are multifaceted and are more receptive to styles that address the whole picture, rather than just small aspects.

*References available upon request