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Professionalization of the Field of Clinical Mental Health Counseling


Chapter 5: 

Self-Care Assessments for Clinical Mental Health Counselors

 Personal and Professional Balance


By Jim Messina, Ph.D., CCMHC, NCC, DMHCS

LEARNING OBJECTIVES

SELF-ASSESSMENT FOR CMHC PERSONAL & PROFESSIONAL BALANCE

You will learn the answers to the following questions:

  1. Why is it important for graduate trainees in Clinical Mental Health Counseling to assess their Self-Esteem at this point in time?
  2. Why is it important for Clinical Mental Health Counselors to regularly do a personal mental health checkup and assess their Self-Esteem, Compassion Fatigue, Burnout and Resilience?
  3. What are the components of Healthy Self-Esteem and why is it so important for CMHCs to have Healthy Self-Esteem?
  4. What are the contributing factors to Compassion Fatigue and why is it so important for CMHCs to lessen the impact of these factors in their lives?
  5. What are the contributing factors to Burnout and why is it so important for CMHCs to lessen the impact of these factors in their lives?
  6. What are the contributing factors to healthy Resilience and why is it so important for CMHCs to work at strengthening these factors in their lives?
  7. Why is it important to for CMHCs to seek out help for themselves when they realize that they are in need of external help to get back on track again?
  8. What activities can CMHCs do to insure they they are practicing good self-care?
  9. What free apps are available that CMHCs can utilize in their self-care plan?
  10. What are some good references you can use to learn more indepth information about the Self-Care for CMHCs?

Why do Clinical Mental Health Counselors Need to Do Ongoing Self-Assessments?

A counselor needs to exist in a high state of congruency and authenticity to benefit the therapeutic alliance and thus, the client. However, occupational hazards abound in the counseling profession. These risk factors can impair the emotional health of therapists in subtle ways often undetectable by the clinicians themselves. For this reason, this chapter describes common maladaptive patterns in clinicians and includes some self-assessment tools for busy counselors. 

Many factors combine to impair therapists’ mental health and to create counselor burn-out: the daily clinical workload, the trauma which clients present, the stresses of managing clinical interventions, the conflict inherent in clinical assessment, requirements of documentation, ethics and liability issues and case management issues. These facets of a counseling practice can challenge self-esteem, self-confidence and self-efficacy, often resulting in compassion fatigue and/or burnout and taxing counselor resilience. To insure long term mental health CMHCs can take the opportunity at least quarterly to perform the following self-assessments. 

Self-Esteem Inventory Assessment for Clinical Mental Health Counselors 

(Messina, 2013d)


Self-Esteem Inventory for CMHCs

DIRECTIONS: Use the following rating scale to indicate the frequency of the following attitudes or behaviors in your daily life.

          1                                               5                                                     10

never exhibit………….…occasionally exhibit………………..frequently exhibit

 

1. 1 2 3 4 5 6 7 8 9 10 I seek approval and affirmation from others, and I am afraid of criticism.

2. 1 2 3 4 5 6 7 8 9 10 I guess at what normal behavior is, and I usually feel as if I am different from other people.

3. 1 2 3 4 5 6 7 8 9 10 I isolate myself from and am afraid of people in authority roles.

4. 1 2 3 4 5 6 7 8 9 10 I am not able to appreciate my own accomplishments and good deeds.

5. 1 2 3 4 5 6 7 8 9 10 I tend to have difficulty following a project through from beginning to end.

6. 1 2 3 4 5 6 7 8 9 10 I get frightened or stressed when I am in the company of an angry person.

7. 1 2 3 4 5 6 7 8 9 10 In order to avoid a conflict, I find it easier to lie than tell the truth.

8. 1 2 3 4 5 6 7 8 9 10 I have problems with my own compulsive behavior, e.g., drinking, drug use, gambling, overeating, smoking, use of sex, shopping, etc.

9. 1 2 3 4 5 6 7 8 9 10 I judge myself without mercy. I am my own worst critic, and I am harder on myself than I am on others.

10. 1 2 3 4 5 6 7 8 9 10 I feel more alive in the midst of a crisis, and I am uneasy when my life is going smoothly; I am continually anticipating problems.

11. 1 2 3 4 5 6 7 8 9 10 I have difficulty having fun. I don't seem to know how to play for fun and relaxation.

12. 1 2 3 4 5 6 7 8 9 10 I am attracted to others whom I perceive to have been victims, and I develop close relationships with them. In this way I confuse love with pity, and I love people I can pity and rescue.

13. 1 2 3 4 5 6 7 8 9 10 I need perfection in my life at home and work, and I expect perfection from others in my life.

14. 1 2 3 4 5 6 7 8 9 10 I seek out novelty, excitement, and the challenge of newness in my life with little concern given to the consequences of such action.

15. 1 2 3 4 5 6 7 8 9 10 I take myself very seriously, and I view all of my relationships just as seriously.

16. 1 2 3 4 5 6 7 8 9 10 I have problems developing and maintaining intimate relationships.

17. 1 2 3 4 5 6 7 8 9 10 I feel guilty when I stand up for myself or take care of my needs first, instead of giving in or taking care of others' needs first.

18. 1 2 3 4 5 6 7 8 9 10 I seek and/or attract people who have compulsive behaviors (e.g., alcohol, drugs, gambling, food, shopping, sex, smoking, overworking, or seeking excitement.)

19. 1 2 3 4 5 6 7 8 9 10 I feel responsible for others and find it easier to have concern for others than for myself.

20. 1 2 3 4 5 6 7 8 9 10 I am loyal to people for whom I care, even in the face of evidence that the loyalty is undeserved.

21. 1 2 3 4 5 6 7 8 9 10 I cling to and will do anything to hold on to relationships because I am afraid of being alone and fearful of being abandoned.

22. 1 2 3 4 5 6 7 8 9 10 I am impulsive and act too quickly, before considering alternative actions or possible consequences.

23. 1 2 3 4 5 6 7 8 9 10 I have difficulty in being able to feel or to express feelings; I feel out of touch with my feelings.

24. 1 2 3 4 5 6 7 8 9 10 I mistrust my feelings and the feelings expressed by others.

25. 1 2 3 4 5 6 7 8 9 10 I isolate myself from other people, and I am initially shy and withdrawn in new social settings.

26. 1 2 3 4 5 6 7 8 9 10 I feel that I am being taken advantage of by individuals and society in general; I often feel victimized.

27. 1 2 3 4 5 6 7 8 9 10 I can be over responsible much of the time, but I can be extremely irresponsible at other times.

28. 1 2 3 4 5 6 7 8 9 10 I feel confused and angry at myself and not in control of my environment or my life when the stresses are great.

29. 1 2 3 4 5 6 7 8 9 10 I spend a lot of time and energy rectifying or cleaning up my messes and the negative consequences of ill-thought out or impulsive actions for which I am responsible.

30. 1 2 3 4 5 6 7 8 9 10 I deny that my current problems stem from my past life. I deny that I have stuffed in feelings from the past which are impeding my current life.

Interpretation of Results

Items rated

6 or Lower

5 or Fewer

Items

6-10

Items

11-15

Items

16-20

Items

21-25

Items

26-30

Items

Level of Esteem

Healthy

Self-Esteem

Traces of

Low

Self-Esteem

Emerging

Low

Self-Esteem

Moderate

Low

Self-Esteem

Very Low

Self

Esteem

Severe

Low

Self

Esteem

Action Needed

None

Monitor Closely

Monitor Closely and Possibly Seek

Consultation

Seek Consultation and Possibly

Psycho-

therapy

Seek Consultation and Probable Psycho-

therapy

Seek

Consultation and Immediate

Psycho-therapy

 

Messina (2013d) suggests that CMHCs have healthy self-esteem who total fewer than five items rated 6 or lower (with the rest rated 7 or higher). CMHCs who total 6-10 items rated 6 or lower (with the rest rated 7 or higher) have traces of low self-esteem and need to monitor their levels closely. CMHCs who accrue 11-15 items rated 6 or lower (with the rest rated 7 or higher) have the presence of emerging low self-esteem and not only need to monitor themselves closely but would be well-served to seek out consultation from seasoned professional colleagues. At this level, clinical work may negatively affect counselors who need strategies for regaining or restoring stable self-esteem. CMHCs who have 16-20 items rated 6 or lower (with the rest rated 7 or higher) have the presence of moderately low self-esteem and would be best served not only by seeking professional consultation but by considering some personal psychotherapy for themselves. CMHCs who have 21-25 items rated 6 or lower (and the rest rated 7 or higher) have the presence of very low self-esteem and should engage in professional consultation and personal psychotherapy. CMHCs who have 26-30 items rated 6 or lower (with the remaining rated 7 or higher) have severe low self-esteem.  These CMHCs should immediately receive personal counseling. Their therapy should address those issues impacting self-esteem and how to ameliorate any negative effects their low self-esteem has upon their clients.

 

Zeigler-Hill, Besser, Myers, Southard, & Malkin, (2012) found that high levels of self-esteem were generally associated with the perception of positive personality characteristics, for this reason it is important for CMHCs to continue to grow in self-acceptance, self-empowerment and self-confidence in order to work with their clients in as relaxed and competent manner as possible.

 

The Components of Clinical Mental Health Counselors Healthy Self-Esteem

Clinical Mental Health Counselors with healthy self-esteem, hold themselves as worthy to be loved and to love others, worthy to be cared for and to care for others, and worthy to be nurtured and to nurture others.  They feel worthy to be touched and supported and to touch and support others, worthy to be listened to and to listen to others, worthy to be recognized and to recognize others. Healthy CMHCs feel worthy to be encouraged and to encourage others, worthy to be reinforced as “good'' people and to recognize others as “good'' people (Messina, 2013e).

 

CMHCs with healthy self-esteem have productive personalities meaning that they have achieved success to the best of their ability in school, work, and society. These CMHCs are capable of being creative, imaginative problem solvers and are calculated risk takers with an optimistic approach to life and goal attainment. CMHCs incorporate these qualities in addition to displaying leadership and people skills especially with their clients. They are neither too independent of nor too dependent upon others. These CMHCs have the ability to size up a relationship and adjust to the demands of the interaction which make them capable of having satisfactory helping relationships with their clients (Messina, 2013e). 

 

CMHCs who have healthy self-esteem, have a healthy self-concept. Their perception of themselves is in synchrony with the picture of themselves they project to others. These CMHCs are able to state clearly who they are, what their potential is, and to what they are committed in life. Healthy CMHCs are able to declare what they hope to achieve in their lifetime. They are not ashamed to self-disclose their weaknesses, faults and failing with their clients since they are aware they are role-modeling healthy self-esteem (Messina, 2013e).

 

CMHCs with health self-esteem are accountable to self and others while accepting the responsibility for and consequences of their actions. These CMHCs do not resort to shifting the blame or using others as scapegoats for actions that have resulted in a negative outcome. These CMHCs own and accept their responsibility for all the interactions they experience in life (Messina, 2013e).

           

CMHCs with healthy self-esteem are altruistic and have a legitimate concern for the welfare of others. Good CMHCs are not self-centered or egotistical in their outlook on life. They do not take on the responsibility for others in an over-responsible way and help others accept the responsibility for their own actions. Healthy CMHCs are always ready to help anyone who legitimately needs assistance or guidance while respecting their own and others’ personal, physical and emotional boundaries. Healthy CMHCs are often the first to offer help for people in need and often do so with no need or expectation of recognition for this generosity of spirit (Messina, 2013e).

           

CMHCs with healthy self-esteem display healthy coping skills. They are able to handle the stresses in their lives in a productive way. They are able to put the problems, concerns, issues, and conflicts that come their way into perspective. They are able to keep their lives in perspective without becoming too idealistic or too morose. They are survivors in the healthiest sense of the word. They have a good sense of humor and are able to keep a balance of work and fun in their lives.  Given these characteristics, it is clear that they work on their resilience and unconditional acceptance of self and others (Messina, 2013e).

 

Finally, CMHCs with healthy self-esteem look to the future with optimism and a sense of adventure. They recognize and visualize their potential for success and have dreams, hopes, and aspirations for the future. They are goal-oriented with a sense of balance when working toward their goals. They know from whence they come, where they are now, and where they are going (Messina, 2013e). ). Those who desire to become Clinical Mental Health Counselors will develop themselves so that they possess a healthy self-esteem which will building their resilience and enable them to them to avoid compassion fatigue or burnout in their future careers.

 

Negative Impacts on Clinical Mental Health Counselor’s Self-Esteem

Theriault and Gazzola (2006) believe that feelings of incompetence plague therapists independent of the actual efficacy of their work. They say that feelings of incompetence arise when therapists’ beliefs in their abilities, judgment, and/or effectiveness in their role as therapists are temporarily challenged internally. Therapists’ feelings of incompetence are self-depreciating, subjective evaluations of their performance as clinicians. These attitudes are personally harmful for the therapist and they may negatively influence the process of therapy (Theriault & Gazzola, 2006). Low self-efficacy, low mastery, and self-doubt are often other ways of describing feelings of incompetency. These terms all relate to a lowering of the self-esteem of the counselors experiencing these feelings.

 

Lee, Cho, Kissinger and Ogle (2010) point out that the high degree of empathy provided by counselors within the context of the therapeutic environment may increase their vulnerability to compassion fatigue. As a coping strategy, counselors with low self-esteem may devalue many parts or even most parts of the client's story. This weakened response to client needs could sabotage the therapeutic alliance and diminish treatment efficacy. CMHCs must be self-aware thus insuring that their own low self-esteem does not harm their effectiveness with clients and more importantly does “no harm” to their clients.

 

Positive Impact of Clinical Mental Health Counselors Healthy Self-Esteem

It is important that CMHCs recognize that their professional association AMHCA in its Code of ethics requires that counselors take on the responsibility to work at monitoring their own physical and mental health so that it does not impact the well-being of their clients (AMHCA, 2010)

 

AMHCA Code of Ethics Related to CMHC Personal Mental and Physical  Health (AMHCA, 2010)

C. Counselor Responsibility and Integrity

1. Competence

     The maintenance of high standards of professional competence is a responsibility shared by all mental health counselors in the best interests of the client, the public, and the profession. Mental health counselors:

a) Recognize the boundaries of their particular competencies and the limitations of their expertise.

h) Recognize that their effectiveness is dependent on their own mental and physical health. Should their involvement in any activity, or any mental, emotional, or physical health problem, compromise sound professional judgment and competency, they seek capable professional assistance to determine whether to limit, suspend, or terminate services to their clients.

i) Have a responsibility to maintain high standards of professional conduct at all times.

k) Are aware of the intimacy of the counseling relationship, maintain a healthy respect for the integrity of the client, and avoid engaging in activities that seek to meet the mental health counselor's personal needs at the expense of the client.

l) Will actively attempt to understand the diverse cultural backgrounds of the clients with whom they work. This includes learning how the mental health counselor's own cultural/ethical/racial/religious identity impacts his or her own values and beliefs about the counseling process.

 

Williams, Richardson, Moore, Gambrel and Keeling (2010) pointed out that the American Counseling Association Code of Ethics identifies self-care as a professional responsibility. This duty requires counselors to engage in self-care activities to promote their emotional, physical, mental, and spiritual well-being to successfully meet their professional obligations. As an ethical mandate, CMHCs must take steps to nurture, strengthen, enhance and strengthen their individual-self-esteem.

 

Yu (2007) reported that counselors' collective self-esteem impacts how clinicians identify themselves in the counseling profession. Additionally, collective identity affects the interplay of job satisfaction and counselor-client relationships. Lent & Schwartz (2012) recommend restorative activities such as exercise, meditation, sharing feelings with a friend, spending time in leisure activities, or drawing on spiritual resources as vital self-care strategies for counselors to buttress self-esteem and to prevent burnout. By taking these preventive step CMHCs can relieve the stressors which contribute to burnout and compromise counselor effectiveness.

 

Richards, Campenni and Muse-Burke (2010) examined the direct effect of self-care on self-awareness (knowledge of one's thoughts, emotions, and behaviors) and mindfulness (awareness of and attention to oneself and one's surroundings) and how these associations affect the well-being of mental health professionals. These researchers found that both self-awareness and mindfulness are significantly and positively related. They also found that the link between perceived importance of self-care and well-being is indirectly affected by mindfulness. Clearly the self-esteem of CMHCs benefitted from the self-care, self-awareness and mindfulness activities in which they engaged (Richard et al., 2010).

 

Stauffer and Pehrsson (2012) encouraged professional counselors to incorporate the practice of mindfulness in their own lives on a daily basis so that can be better prepared to help clients implement this practice in their own lives. In this way CMHCs engage in positive activities to protect their self-esteem from emotional stressors triggered by the array of client issues.

 

Daw and Joseph 2007) documented that CMHCs who received personal counseling experienced improved self-esteem, work functioning, social life, emotional expression and symptom severity. These counselors attributed the improvement to their involvement in psychotherapy. These findings supports the assertion that practicing CMHCs be open to consider receiving personal counseling if their self-esteem begins to drop below the “Healthy Self-Esteem” range. This strategy may prevent therapeutic harm to the clinician and/or clients in treatment.

 

Apps for Building Self-Esteem

LifeArmor: CMHCs or students in CMHC can self-monitor emotional experiences associated with low-self-esteem and behavioral health issues like post-traumatic stress, brain injury, life stress, depression and anxiety. Read more about it at: http://t2health.org/apps/lifearmor

 

Mood Tracker: This app enables CMHCs or students in CMHC to self-monitor, track and reference their emotional experiences over a period of days, weeks, and months. Users can self-monitor emotional experiences associated with common low-self-esteem and behavioral health issues like post-traumatic stress, life stress, depression and anxiety. Read more about it at: http://t2health.org/apps/t2-mood-tracker

 

Quitter: This app is set up so that CMHCs or students in CMHC can monitor their efforts to cease any bad behavior(s) of their choosing to increase their physical and mental health. Read more about it at: http://itunes.apple.com/us/app/quitter/id284944935?mt=8

 

Self-Esteem Issues for Counselors in Training

            Wellness is important for counselors in training and their future clients. Hartwig-Moorhead, Gill, Barrio-Minton and Meyers (2012) found that attending to forgiveness may enhance wellness and may serve as a valuable preventive tool for counselors while in training and later in practice. Additionally, enhancing wellness may help counselors develop coping skills to forgive in a healthy manner. Both aspects will support the self-esteem of counselors in training.

 

Burkholder (2012) posited a model for professional identity for counselor trainees. The model is based on the concept that professional identity is the integration of personal attributes and professional training, its expression is the manifestation of that integration. Counselor identity is manifested in any observable behavior of an individual within a professional context, such as a CMHC providing therapy for a client. For this reason counselors in training need a sound foundation of personal wellness and self-esteem so that their best professional identity is reflected when engaged with clients.

           

Oden, Miner-Holden & Balkin (2009) addressed the issue of required counseling for mental health professional trainees and pointed out that CACREP supports the belief that self-awareness is important for mental health professionals. One CACREP requirement stipulates that accredited programs provide curricular experiences for their students to facilitate student self-awareness. This awareness supports a therapeutic counselor-client relationship and appropriate professional boundaries. Oden et al. conducted research in a setting which required counselors in training to receive individual counseling for themselves. These researchers found that a large percentage of participants reported their individual counseling brought about a moderate to high increase in their awareness of their interactions with clients, assisted in understanding the role of the counselor and the process of counseling, helped them to understand what it is like to be a client, and enabled counselor genuineness and empathy for clients (2009).

           

Ikiz (2011) suggested that counselor education is actually personality and skill development education. Ikiz’s research found that trainee counselors’ personal evaluations about their physical appearance (self-evaluations about their self-images) were found to have an effect on their assertiveness (2011). Ikiz also stated that possessing a positive self-image - which is one measure of well-being - is a core condition for a person’s self-acceptance in addition to autonomy, positive relationships with others, and purpose in life (2011). Ikiz concluded that self-acceptance enhances assertiveness and a more positive self-image results in greater assertiveness (2011). Counselors in training should be encouraged to consider their self-acceptance, self-image and ability to be assertive in healthy ways as a support to self-esteem.

 

Finally Campbell and Christopher (2012) encourage in counselor training the use of practices such as mindfulness meditation, yoga, qigong, and body awareness to assist counselors in training to embody the attributes of a healthy therapeutic process. By incorporating these self-care practices in counselor education programs the graduate students will also grow in personal self-esteem which can mitigate the negative impact of compassion fatigue, an inherent risk in the counseling profession.

Compassion Fatigue Inventory for Clinical Mental Health Counselors

(Messina, 2013a)


 Compassion Fatigue Inventory

Directions: Choose the rating on scale of 1-10 for each of the following items as it applies to you currently.

1                              5                                           10

never experience.……occasionally experience……..frequently experience

 

 

 

1.

1 2 3 4 5 6 7 8 9 10

Overstressed, muscle tightness, having difficulty sleeping

2.

1 2 3 4 5 6 7 8 9 10

Feeling of being “under supported,” sensing that others are “uncaring”

3.

1 2 3 4 5 6 7 8 9 10

A sense of being lackadaisical

4.

1 2 3 4 5 6 7 8 9 10

Chronic feeling of “being sick,” overtired, or having general fatigue

5.

1 2 3 4 5 6 7 8 9 10

State of being worried: “having concerns on my mind”

6.

1 2 3 4 5 6 7 8 9 10

Asking “Why do I stay here?”

7.

1 2 3 4 5 6 7 8 9 10

Feelings of guilt

8.

1 2 3 4 5 6 7 8 9 10

Disillusionment on the job or with home life

9.

1 2 3 4 5 6 7 8 9 10

Feelings of being “let down”

10.

1 2 3 4 5 6 7 8 9 10

Speaking of work or home as if I am not the “real me” when there

11.

1 2 3 4 5 6 7 8 9 10

Feelings of helplessness like a victim

12.

1 2 3 4 5 6 7 8 9 10

Desire to be allowed to be the “real me” at home or on the job

13.

1 2 3 4 5 6 7 8 9 10

Feeling that too many expectations are heaped on me

14.

1 2 3 4 5 6 7 8 9 10

Blaming others for everything

15.

1 2 3 4 5 6 7 8 9 10

Lack of caring for family, co-workers, others

16.

1 2 3 4 5 6 7 8 9 10

Feelings of self-righteousness

17.

1 2 3 4 5 6 7 8 9 10

Feeling and acting very defensively

18.

1 2 3 4 5 6 7 8 9 10

Maintaining an unapproachable attitude

19.

1 2 3 4 5 6 7 8 9 10

Questioning personal values and judgments

20.

1 2 3 4 5 6 7 8 9 10

Feeling intimidated by people

21.

1 2 3 4 5 6 7 8 9 10

Asking “Is this all there is?”

22.

1 2 3 4 5 6 7 8 9 10

Lack of interest in the outside world

23.

1 2 3 4 5 6 7 8 9 10

Cutting self-off from family and/or friends

24.

1 2 3 4 5 6 7 8 9 10

Feeling like “I am working harder but experiencing fewer successes”

25.

1 2 3 4 5 6 7 8 9 10

Feeling unappreciated

26.

1 2 3 4 5 6 7 8 9 10

Escaping into increased workload

27.

1 2 3 4 5 6 7 8 9 10

Desiring to run away

28.

1 2 3 4 5 6 7 8 9 10

Continuous state of depression, feeling down or blue

29.

1 2 3 4 5 6 7 8 9 10

Not willing to take time for a vacation because “I’ve got to work”

30.

1 2 3 4 5 6 7 8 9 10

Frustration with the system

31.

1 2 3 4 5 6 7 8 9 10

Feelings of paranoia

32.

1 2 3 4 5 6 7 8 9 10

Not looking forward to coming to work in the morning

33.

1 2 3 4 5 6 7 8 9 10

Daydreaming or fantasizing during the day

34.

1 2 3 4 5 6 7 8 9 10

Sense of failure in everything I try

35.

1 2 3 4 5 6 7 8 9 10

Tendency to catch more minor illnesses and staying sick longer

36.

1 2 3 4 5 6 7 8 9 10

Withdrawal from important relationships

Interpretation of Results

Ratings of items

0-2 items at 8 or greater

Or

0-4 items at 6 or greater

3 or more items at 8 or greater Or

5-10 items at 6 or greater

Action Needed

Continue self-care

Practices

Increase self-care

Practices

Consider Consultation

 

Messina (2013a) points out that individuals who rated three or more items at 8 or higher or if they rated 5-10 items at 5 or higher, they are most likely experiencing some level of compassion fatigue and need to take steps to prevent the negative effects of the disabling syndrome. 

Components of Compassion Fatigue

Clinical Mental Health Counselors are prone to “compassion fatigue” as a result to repeated exposure to clients who have experienced extreme trauma in their lives. Examples of trauma include: Surviving physical, sexual or emotional abuse; dealing with life-threatening illness; serving in military combat, becoming disabled, and surviving or witnessing torture, accidents, or disasters of any cause.

           

Compassion fatigue is conceptualized as a combination of secondary traumatization and burnout precipitated by the care delivery that brings health-care professionals into contact with the suffering (Szabo, 2006). "Compassion fatigue is when caregivers have such deep empathy they develop symptoms of trauma similar to the patient” according to director of the Army Institute of Surgical Research, Colonel Kathryn Gaylord (Wilson, 2008). This condition can also resemble the burnout which occurs when emotional exhaustion occurs due to increased workload and institutional stress regardless of trauma exposure. Compassion fatigue can have detrimental effects on counselor-client relationships since the counselor suffering from this condition has difficulty regulating the emotional distance with the client. The alliance can become either too distant or too close for a good outcome.

            Counselors who experience continued, close contact with trauma survivors may also experience emotional disruption known as “secondary traumatic stress”. This disruption can be a natural, consequent set of behaviors and emotions resulting from knowledge about a traumatizing event experienced by a client. It can also be due to the stress resulting from helping or wanting to help a traumatized or suffering person (Bride, 2007).

            Clinical Mental Health Counselors need to develop a sense of “compassion satisfaction” which is the ability to derive a great sense of meaning and purpose from clinical work. This satisfaction may aid in alleviating the stresses endemic to the human condition at large and the specific challenges of compassion fatigue.  Compassion satisfaction may be an important buffer in managing and transcending alterations in belief systems and physiological or emotional reactions seen in compassion fatigue (Tyson, 2007).

 

Figley (1995) identified four major factors which contribute to compassion fatigue. These factors include: 1. Poor self-care, 2. Previous unresolved trauma, 3. Inability or refusal to control work stressors and 4. Lack of satisfaction from work. For nurses who work in hospice care, the following four factors were identified contributing to compassion fatigue which are applicable to CMHCs who work with this population. These factors include: 1. Trauma, 2. Anxiety, 3. Life demands and 4. Excessive empathy (leading to blurred professional boundaries) (Abendroth and Flannery, 2006). This last factor is a significant challenge for many new CMHCs.

 

App for CMHC to Prevent Compassion Fatigue

Provider Resilience Provider Resilience gives CMHC’s and Students in CMHC tools to guard against burnout and compassion fatigue as they help their clients be they civilians or service members, veterans, and their families. Providers can take a self-assessment to determine if they are at risk and steps they can take to ward off such burnout and fatigue. Read more about it at: https://www.t2health.org/apps/provider-resilience

 

      Clinical Mental Health Counselors need to ensure that they are functioning at their best in the therapeutic relationship. Facilitating personal well–being and avoiding burnout is clearly one way in which this goal can be achieved (Linley and Joseph, 2007). 

Burnout Prevention Inventory for Clinical Mental Health Counselors

(Messina, 2013b)


Self-Assessment of Clinical Mental Health Counselor Burnout

Rate each of the following feelings from 1 to 10 as it applies to your life.

   1                       5                                    10

         never        occasionally       frequently experienced

  1. 1 2 3 4 5 6 7 8 9 10 Feeling overstressed, tightness in back and shoulders, having difficulty sleeping
  2. 1 2 3 4 5 6 7 8 9 10 Feelings of being under supported, sensing that others are uncaring
  3. 1 2 3 4 5 6 7 8 9 10 Feeling a sense of being lackadaisical
  4. 1 2 3 4 5 6 7 8 9 10 Feelings of being sick, overtired, or having general fatigue
  5. 1 2 3 4 5 6 7 8 9 10 Feeling worried, in a chronic state of having concerns on my mind
  6. 1 2 3 4 5 6 7 8 9 10 Feeling stuck which includes asking: Why do I stay here?
  7. 1 2 3 4 5 6 7 8 9 10 Feelings of guilt
  8. 1 2 3 4 5 6 7 8 9 10 Feelings of disillusionment on the job or with home life
  9. 1 2 3 4 5 6 7 8 9 10 Feelings of being let down
  10. 1 2 3 4 5 6 7 8 9 10 Feelings as if I am not the real me when speaking of the work or home setting
  11. 1 2 3 4 5 6 7 8 9 10 Feelings of helplessness, feeling like a victim
  12. 1 2 3 4 5 6 7 8 9 10 Feeling a desire to be allowed to be the real me at home or on the job
  13. 1 2 3 4 5 6 7 8 9 10 Feeling that many expectations are heaped on me
  14. 1 2 3 4 5 6 7 8 9 10 Feeling like always blaming others for everything
  15. 1 2 3 4 5 6 7 8 9 10 Feeling a lack of caring for family, coworkers, others
  16. 1 2 3 4 5 6 7 8 9 10 Feelings of self-righteousness
  17. 1 2 3 4 5 6 7 8 9 10 Feeling and acting very defensively
  18. 1 2 3 4 5 6 7 8 9 10 Feeling wanting to left alone and maintaining an unapproachable attitude
  19. 1 2 3 4 5 6 7 8 9 10 Feeling loads of self-doubt, questioning personal values and judgments
  20. 1 2 3 4 5 6 7 8 9 10 Feelings of being intimidated by people
  21. 1 2 3 4 5 6 7 8 9 10 Feeling disillusioned, asking Is this all there is?
  22. 1 2 3 4 5 6 7 8 9 10 Feeling lack of interest in the outside world
  23. 1 2 3 4 5 6 7 8 9 10 Feeling as if cut off from family and/or friends
  24. 1 2 3 4 5 6 7 8 9 10 Feeling, I'm working harder than ever before but experiencing fewer successes.
  25. 1 2 3 4 5 6 7 8 9 10 Feeling unappreciated
  26. 1 2 3 4 5 6 7 8 9 10 Feeling like escaping the real work by piling on an increased workload
  27. 1 2 3 4 5 6 7 8 9 10 Feeling the desire to run away
  28. 1 2 3 4 5 6 7 8 9 10 Feeling a continuous state of depression
  29. 1 2 3 4 5 6 7 8 9 10 Feeling not willing to take time for a vacation because there is so much work to do
  30. 1 2 3 4 5 6 7 8 9 10 Feeling frustration with the system
  31. 1 2 3 4 5 6 7 8 9 10 Feeling paranoia
  32. 1 2 3 4 5 6 7 8 9 10 Feeling blank and not looking forward to coming to work in the morning
  33. 1 2 3 4 5 6 7 8 9 10 Feeling distracted by daydreaming or fantasizing during the day
  34. 1 2 3 4 5 6 7 8 9 10 Feeling a sense of failure in everything you try
  35. 1 2 3 4 5 6 7 8 9 10 Feeling sickly with a tendency to contract infections of longer duration and/or experiencing psychosomatic illnesses
  36. 1 2 3 4 5 6 7 8 9 10 Feeling withdrawal from important relationships


Interpretation of Results

Score

 

0-2 items scored 8+

3+ items scored 8+

Action Needed

Continue monitoring

and self-care practices

Increase self-care practices

consider consultation

 

 




Each of the above feelings has been used to describe burnout. If CMHCs have rated three or more items 8 or higher, they are candidates for burnout and it is important for them to work at a plan of action to lessen the impact of burnout in their personal and professional lives (Messina, 2013b).

 

Components of Burnout

Burnout results in loss of focus both at home and on the job. Some external factors which contribute to burnout in Clinical Mental Health Counselors are the following: workplace or home which is stressful and/or disorganized; people at work or home who are stressful, anxious, tense or hostile; and if the counselor’s locus of control resides in the hands of others - supervisors, clients, or family members (Messina, 2013b).

 

Internal factors contributing to burnout in Clinical Mental Health Counselors include the following: Unrealistic performance expectations at workplace or home, overreaction to a specific negative event at home or work, rigid self-concept of “being special”, and depression over not being “good enough.” Another internal risk factor is the failure of not fulfilling an idealistic vision of self as “super-competent”. Finally, in some cases burnout results from feeling more enlightened than others and experiencing frustration at not influencing the ideas or behavior of others (Messina, 2013b). Beliefs that contribute to burnout in CMHCs include this list:

  • I should excel at all times and should not experience problems like other people.
  • Satisfaction in helping others is reward enough for me – I don’t need feedback or recognition.
  • My efforts will always be appreciated by others.
  • Status and prestige accompany my position.
  • I can make dramatic changes through my efforts (Messina, 2013b).

 

Some organizational dynamics which can contribute to Clinical Mental Health Counselor burnout include the following: people in the clinical setting relating poorly (tense hostile, uncooperative); the lines of authority, policies, and procedures enforced with rigidity; unrealistic expectations concerning family or coworker organization; extreme empathy for family members or coworkers due to their being treated as underdogs  by authority figures; excessive authoritarianism by people at home or work: and lack of support mechanisms. Role expectations can contribute to burnout if the roles are rigid and confined.  Rigid demands include excessive work hours and/or overtime hours resulting in less leisure time inflexible dress codes,  or the requirement to be “appropriate” at all times.

Alleviating Burnout for Clinical Mental Health Counselors

Healthy CMHCs admit that burnout is a occupational risk and seek support when required. With family or administrators, clinicians can discuss their self-care priorities. In those discussions counselors can make a list of aspects they dislike on the job or at home and seek ways to eliminate or delegate such tasks. Finally, CMHCs need to develop awareness of their motivations underlying their family relations and of their selection of counseling as a profession (Messina, 2013b). Self-aware CMHCs know the importance of conducting ongoing self-assessments for burnout and to being able to recognize the symptoms.

 

Preventing Burnout in Clinical Mental Health Counselors

 Clinical Mental Health Counselors will want to be informed of the specifications of any new job before accepting a position; Role expectations, scope of responsibilities, opportunity for advancement, supervision, job description, workload, evaluation criteria, benefits, and salary structure are crucial issues. CMHCs need to maintain their personal growth in their clinical work by engaging in a structured routine to set, achieve, and evaluate professional goals. Additionally, counselors can alternate major tasks requiring delayed gratification with those tasks which provide short-term successes. Seeking out supervision for their clinical work helps to maintain a healthy balance between home and career. Counselors also benefit by personalizing their work and home environment with meaningful pictures, objects, books and quotations.

 

Counselors need to learn to ask for support and to be aware of the limitations of their family, their jobs, and themselves. Therapists (and their clients) can learn to change the things that are changeable, accept the things that are not changeable, and develop the wisdom to discern the difference.  CMHCs will want to build a support system for themselves with others who are open to discuss problems and proposed solutions. In these discussions the counselor could make a list of disliked aspects and seek ways to eliminate or delegate such tasks. This interaction is more than a “gripe session” and impels the counselor forward to problem-solving strategies for burnout. (Messina, 2013b).

 

CMHCs need to maintain discipline in their daily responsibilities and duties at home and in the workplace, organizing and prioritizing around vital goals.  Counselors can diversify responsibilities and put more variety in both their clinical work and their home lives and will want to take time during the day to rejuvenate. Busy therapists need to find their own decompression activities such as meditation or exercise that relieve tension and produce a more relaxed state. Outside the workplace, counselors can develop a rich variety of interests and hobbies unrelated to clinical demands. Short vacations twice per year can be helpful.

 

Healthy counselors encourage and model good communication skills in the many dimensions of life. CMHCs can learn to feel comfortable with assertiveness skills and boundary setting skills as well as advocating for new ideas.  An idea as thoughtful as devising flexible working conditions can prevent or ameliorate counselor burnout as can adopting an variety of these self-care practices.

 

Apps for CMHCs to Alleviate Burnout Factors Through Relaxation

& Sleep Related Apps

Breath2Relax: Breathing exercises have been documented to decrease the body's 'fight-or-flight' (stress) response, and help with mood stabilization, anger control, and anxiety management. This app uses diaphragmatic breathing to help CMHCs and students in CMHC reduce their stress. Read more at:http://t2health.org/apps/breathe2relax

 

Tactical Breather: This app can help CMHCs and students in CMHC gain control over physiological and psychological responses to stress. Read more about it at: http://t2health.org/apps/tactical-breather

Sleep Issues Related

CBT-i Coach: This app is to be used with CMHCs and students in CMHC who have sleep problems. They can design their own Sleep prescription to improve their sleeping habits. They have a number of tools at their disposal to do this on the app. They also have an extensive learning program and daily reminders to use to help them improve their sleep. Read more about it at: https://itunes.apple.com/us/app/cbt-i-coach/id655918660?mt=8

 

White Noise HB Lite: This app provides ambient sounds of the environment to help CMHCs and students in CMHC who have problems falling asleep to relax or sleep. Read more about it at: http://itunes.apple.com/us/app/white-noise-lite/id292987597?mt=8

Personal Resilience Inventory for Clinical Mental Health Counselors

The following self-assessment survey (Messina, 2013c) was developed from materials available on resilience in a variety of peer-reviewed journal articles (Ashe, 2006; Harrison, 2002; Ivy, 2003; Lavretsky & Irwin, 2007; and Owen, 2002).


Personal Resilience Self-Assessment for CMHCs

Directions: Choose the rating on scale of 1-10 for each of the following items as it applies to you as a Clinical Mental Health Counselor

                                 1                                  5                                    10

never…………………occasionally……………almost always

 

 

 

1.

1 2 3 4 5 6 7 8 9 10

I consider the cup half full and not half empty during trying times

2.

1 2 3 4 5 6 7 8 9 10

I get plenty of rest and sleep

3.

1 2 3 4 5 6 7 8 9 10

I seek out the ongoing social support of family, friends and others

4.

1 2 3 4 5 6 7 8 9 10

I accept help from others no matter who they are

5.

1 2 3 4 5 6 7 8 9 10

I look for opportunities of self-discovery for my personal growth

6.

1 2 3 4 5 6 7 8 9 10

I work hard to know what role I have played if any in creating trying situations

7.

1 2 3 4 5 6 7 8 9 10

I keep a journal, writing down my thoughts and feelings during trying times

8.

1 2 3 4 5 6 7 8 9 10

I work hard to maintain a positive outlook on my situation

9.

1 2 3 4 5 6 7 8 9 10

I maintain a balanced nutritious diet

10.

1 2 3 4 5 6 7 8 9 10

I maintain a program of daily or regular physical exercise

11.

1 2 3 4 5 6 7 8 9 10

I use stress reducers like meditation, yoga, visualizations, deep breathing

12.

1 2 3 4 5 6 7 8 9 10

I am an open and empathic listeners to others fears, thoughts and feelings

13.

1 2 3 4 5 6 7 8 9 10

I continuously assess how well I am handling the stress during trying times

14.

1 2 3 4 5 6 7 8 9 10

I schedule time each week to have fun

15.

1 2 3 4 5 6 7 8 9 10

I work hard to understand what caused stressful situations to avoid repeating them

16.

1 2 3 4 5 6 7 8 9 10

I sustain my commitment to most things I value and believe in

17.

1 2 3 4 5 6 7 8 9 10

I maintain a daily relaxation training program lasting a minimum of 10-15 minutes

18.

1 2 3 4 5 6 7 8 9 10

I work at networking with other counselors in similar work settings

19.

1 2 3 4 5 6 7 8 9 10

I seek out the people and activities important to me

20.

1 2 3 4 5 6 7 8 9 10

I get my anger out in healthy ways and not on the people around me

21.

1 2 3 4 5 6 7 8 9 10

I maintain a patient attitude and do not expect things to be fixed over night

22.

1 2 3 4 5 6 7 8 9 10

I accept that my feelings of being sad, angry, fearful or anxious are normal in trying times

23.

1 2 3 4 5 6 7 8 9 10

I set goals to overcome the problems and work on achieving them

24.

1 2 3 4 5 6 7 8 9 10

I stick to my routines of work, chores, and hobbies for stability in my life

25.

1 2 3 4 5 6 7 8 9 10

I envision the future to be more productive than current frustrating conditions I experience in my clinical work

26.

1 2 3 4 5 6 7 8 9 10

I seek out coaching and supervision on how to survive effectively in trying times in my clinical work

27.

1 2 3 4 5 6 7 8 9 10

I accept that change is a part of living

28.

1 2 3 4 5 6 7 8 9 10

I talk out my thoughts, fears and feelings with others and do not bottle them up

29.

1 2 3 4 5 6 7 8 9 10

I work hard to be honest with people about the realities I am facing

30.

1 2 3 4 5 6 7 8 9 10

I maintain my sense of humor in the face of adversity

31.

1 2 3 4 5 6 7 8 9 10

I do not allow myself to consider crises as insurmountable problems

32.

1 2 3 4 5 6 7 8 9 10

I draw on my faith and spiritual beliefs to survive and be at peace

33.

1 2 3 4 5 6 7 8 9 10

I draw on the skills from my past when I survived trying times before

34.

1 2 3 4 5 6 7 8 9 10

I seek out others who are resilient in trying times to learn how they thrive under such conditions

35.

1 2 3 4 5 6 7 8 9 10

I volunteer or offer to help out fellow clinicians with their needs when they are facing difficult times

36.

1 2 3 4 5 6 7 8 9 10

I remind myself I have bounced back before and I will do it again


Interpretation of the Personal Resilience Self-Assessment

Scores

0-9 items scoring 8 or higher or

0-14 items scoring 5 or higher

10 or more items scoring 8 or higher or

15 or more items scoring 5 or higher

Action Needed

Monitor resilience

Continue self-care practices

Increase self-care practices

consider consultation

 

If a CMHCs rated 10 or more items 8 or higher or rated 15-20 items 5 or higher, they are more likely to struggle with resilience during stressful times during their professional counseling careers (Messina, 2013c).

 

In the professional career of most Clinical Mental Health Counselors, stressful times will occur due to many factors. The nature of the profession ensures that the CMHCs encounter a rather constant barrage of distressed people – but these people are not just the clients! Co-workers, friends and family members often seek out counselors in social situations to help alleviate personal distress. When stress seems unremitting or when particularly distressing events occur, fears can arise in the counselor.

  • fear of personal ineffectiveness or loss of ability to survive tough times
  • fear of loss of job or economic instability due to stressors
  • fear of negative self-worth and self-esteem resulting from failures
  • fear of increased family or relational difficulties during stressful times

 

Factors Contributing to Resilience

The APA Health Center (APA, 2004) defines “resilience” as the process of adapting well in the face of adversity, trauma, tragedy, threats, or even significant sources of stress -such as family and relationship problems, serious health problems, or workplace and financial stressors. It means "bouncing back" from difficult experiences. The APA Health Center (APA, 2004) reports that the following factors are related to resilience: the capacity to make realistic plans and take steps to carry them out; a positive view of oneself and confidence in one’s strengths and abilities; skills in communication and problem solving; and the capacity to manage strong feelings and impulses. All of these are factors are attainable by Clinical Mental Health Counselors.

 

Ashe (2006) proposed that people need to build resilience to sustain their emotional health when faced with major stressors: wars, layoffs, life-altering events, natural disasters, death, change, divorce, health issues, and financial difficulties among others.  Ashe clarifies that being resilient doesn’t mean difficulty or distress is never experienced. Emotional pain, anger, grief, and sadness are common when you have troubles in tough times. Developing resilience involves behaviors, thoughts and actions that can help you cope with stressful events. It helps restore balance in your life (Ashe, 2006).

 

Resilience encompasses many aspects: dealing positively with adversity, building personal strengths, building positive and nurturing professional relationships, maintaining positivity, developing emotional insight, achieving life balance and spirituality; and becoming more reflective (Jackson, Firtko & Edenburough, 2007). Resilience results in adaptation as measured by at least three factors: high prevalence of stable mental and behavioral health, adequate role functioning at work and home, and a high quality of life (Norris, Stevens, Pfefferbaum, Wyche & Pfefferbaum, 2008).

 

Coutu (2002) believes that resilience in the workplace is a reflexive way of facing or understanding the world, this point of view is deeply etched in a person’s mind and soul and results in facing reality with staunchness. These attributes make meaning of hardship rather than reactively crying out in despair and embracing maladaptive solutions.

 

Martindale (2007) summarized issues which can diminish resilience in aging clients: fear of diminution or loss of one’s personal strength, fear of displacement in work roles by younger workers, possible failure of effectiveness of one’s professional skills, fear that one would not be able to cope with unemployment and loss of identity, and fears about the anxieties arising in marital and family relationships in the case of job loss.

Factors Contributing to Clinical Mental Health Counselor Resilience

APA (2004) reports that people can build resilience in the following ways: making connections to develop a strong social network with others, seeing crises as challenges rather than insurmountable problems, accepting that change is a part of life, moving toward one’s personal and professional goals, taking decisive actions, looking for opportunities for self-discovery, nurturing a positive view of self, keeping things in perspective, maintaining a hopeful outlook, and caring for oneself.

 

If Clinical Mental Health Counselors are working in public or private agency settings with other professionals they can assist their coworkers to survive trying times in many ways: coaching coworkers about how to build their personal resiliency, helping coworkers assess their own level of resilience, and teaching ways to build resilience in trying times. All of these steps will encourage “a resilience building lifestyle” in the clinical workplace (APA 2004).

 

Hoge, Austin & Pollack (2007) encourage the following efforts in clinical settings to encourage the development of resilience within the clinical team: encourage coworkers to be “task-focused” and make coping plans for the future, develop support groups which are “emotion-focused” where the fellow clinicians can express feelings, and keep the clinical team “reality focused” by challenging avoidant coping styles where clinicians refuse to confront the actuality of stressful times.

 

App for CMHC Resilience Building

Goal Setting: CMHCs or students in CMHC can use this App which helps people to build resilience through use of this goal setting program. Read more about it at:   http://itunes.apple.com/us/app/goal-setting-comprehensive/id441222534?mt=8

 

Continuous Resilience Building for Clinical Mental Health Counselors

Clinical Mental Health Counselors need to adopt these affirmations;

  • I can survive and thrive in trying times!
  • I am building my resilience!
  • I can inspire others to cooperate in building our collective resilience! (Messina, 2013c)

References

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American Mental Health Counselors Association. (2010). AMHCA Code of Ethics from    http://www.amhca.org/about/codetoc.aspx

 

APA. (2004). APA Help Center: The road to resilience:

http://www.apahelpcenter.org/featuredtopics/feature.php?id=6 

 

Ashe, L. (2006). In times of trouble build resilience. Methodist Healthcare Employee

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Bride, B. (2007). Prevalence of secondary traumatic stress among social

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Bride, B., Radey, M. & Figley, C.R. (2007). Measuring compassion fatigue. Clinical

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Burkholder, D. (2012). A model of professional identity expression for mental health

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Campbell, J.C. & Christopher, J.C. (2012). Teaching mindfulness to create effective

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Coutu, D. (2002). How resilience works. Harvard Business Review, 80(5), 46-51. 

 

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Hartwig-Moorhead, H.J. H., Gill, C.,V., Barrio-Minton, C.A. & Meyers, J.E. (2012).

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Ikiz, F,E, (2011). Self-perceptions about properties affecting assertiveness of trainee

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WHERE DO I GO FROM HERE?

CONCERNING SELF-ASSESSMENT FOR CMHC

 PERSONAL & PROFESSIONAL BALANCE

Now that you have read this section, in “Professional CMHC Journal” record your answers and reactions to the following questions:

  1. How will this information help me as a Clinical Mental Health Counselor?
  2. How open am I to get help for myself if my self-esteem is not as healthty as it needs to be so that I can be successful as a CMHC?
  3. How willing and committed am I to implementing a plan of action for regular personal mental health check-ups by assessing for self-esteem, compassion fatitgue, burnout and resilience?
  4. What more do I need to learn about: 1) Self-Esteem; 2) Compassion Fatigue; 3) Professional Burnout; and 4) Building Personal Resilience?
  5. What will be the components of my personal self-care, healthy lifestyle plan of action to insure I am physically and mentally healthy in my professional work as a CCMHC?
  6. Where can I go to get more information about Self-Care for CMHCs?
  7. Where can I go to get journal articles on Self-Care for CMHCs?
Now that you have completed the five chapters of this monograph answer the following questions:


WHERE DO I GO FROM HERE?

Professionalization of the field of Clinical Mental Health Counseling

Now that you have read this section, in “My Professional CMHC Journal” record your answers and reactions to the following questions:

  1. Now knowing why the profession of clinical mental health counseling was founded, why is this relevant to me and my choice in becoming a CMHC?
  2. Now knowing the rationale and purpose of AMHCA and why is it important for me to join AMCHA at the national, state and local level?
  3. Now knowing what accreditation means so why is CACREP accreditation important to me in the choice I made on entering the training program I am in today?
  4. Now knowing about national certification as a Certified Clinical Mental Health Counselor (CCMHC) what am I going to do to insure I attain it?
  5. What am I be willing to do to promote the ongoing recognition and acceptance of the field of Clinical Mental Health Counseling as legitimate and viable profession?
  6. Since I am limited by my state’s licensure law under which title I will gain licensure, what can I do if I am going to be an LPC, to be called a Clinical Mental Health Counselor in my state, so that I can be recognized as a member of a Mental Health Profession?
  7. What can I do to work at promoting portability of licensure from state to state and by the use of the CCMHC to make this happen?
  8. How concerned am I the future of the Clinical Mental Health Counseling Profession with the implementation of the National Affordable Care Act and what steps will I take to insure my CMHC credential will have value and worth as my professional career progresses?
  9. What new trends in the Mental Health Field do I as a futurre Clinical Mental Health Counsel need to embrace? And why is this so important?
  10. Why is it important that I belong to both AMHCA and ACA at the national, state and local level?
  11. Why do I need to know and abide by both the AMHCA and ACA Codes of Ethics as a CMHC?
  12. Will I be willing to keep up with the research on the CMHC profession’s clinical work?
  13. Am I ready to pursue becoming a professional now that I know the depth of the obligations becoming a professional entails?
  14. Am I open to becoming a professional Clinical Mental Health Counselor no what matter barriers I face as I proceed in training for and attaining the credentials necessary in this journey into professionalism?