Defining Counselling Part 2: A Practitioner’s Approach

Defining Counselling: Part 2 of 3, as featured in Vol 23 No 2 Winter 2022 of the Counselling Australia Journal.

In this second instalment, we talk to doctor-turned-counsellor Vicky Dawes about the importance of counsellors and its distinction from the medical field.

 

By Larissa Dubecki

After seven years of working as a doctor in emergency medicine, Vicky Dawes had reached burnout. “It’s a really common phenomenon,” she says. “But it’s only recently been spoken about more openly. It’s related to the work environment – very stressful, high pressure, little room for taking a break. Then you can add to that the fact that medicine does attract these high achievers who throw themselves into their careers. The telling thing is that burnout does happen to a massive number of doctors.”

Now a clinical counsellor, Vicky can look back and see certain augurs had anticipated her shift to counselling: “While I was in medicine, I always loved seeing people who essentially needed counselling. The other doctors would say, ‘Vicky, can you go and see this person because I don’t know how to handle this’ – because they didn’t know how to handle it. It’s undervalued how important it is, often with people who are quite distressed.”

Taking the leap from emergency medicine to counselling – with a short-lived stint of psychiatrist training in between – has proven a fortuitous one for Vicky. A graduate of the University of Queensland with a Master of Counselling, she spent five years as counsellor and educator for a not-for-profit doctors’ health service, supporting doctors and medical students with their own mental health and wellbeing.

Now in private practice, Vicky specialises in bespoke therapy for doctors, professionals and university students. “Going from medicine, which is socially held up on a pedestal, to counselling – which in many ways isn’t – has been interesting. But I absolutely love it,” she says. “Giving patients the permission to be vulnerable and responding to shame with empathy is enormously powerful. I really do think that counselling proves, in bucketloads, the importance of the therapeutic relationship.”

Defining Counselling Part 2: A Practitioner's Approach

From doctor to counsellor:  a cultural shift

Vicky observes from her real-life experience that medicine and counselling are seen in vastly divergent ways, even though both are patient based. “In my former career as a doctor, I had been taught how to efficiently take a history from a patient, examine their body for signs and symptoms, come up with a diagnosis and differentials, and start treatment – based off the best evidence available at the time,” she says.

“As a medical practitioner I was often positioned as expert. Moving into counselling was a complete shift in both mindset and approach. While both roles encourage the doctor or counsellor to approach the patient or client from a position of curiosity and not knowing, in counselling I learned the immense value of deep empathic listening, of recognising the client as expert in their own lives, and of the power of walking alongside someone in their time of need rather than telling them what was ‘wrong’ or jumping in to ‘fix it’. While ‘bedside manner’ is touched upon in medical training, counselling recognises the profound importance of the therapeutic alliance underpinning whatever therapeutic approach is taken.”

Her own professional shift revealed the cultural weight applied to the hierarchies apportioned to the health industry.

Vicky says she was seen to ‘abandon’ the more culturally valued field of medicine. “It was culturally unacceptable, especially to doctors of a certain age who would say things like ‘oh, that’s a shame’ when they found out I was leaving – or to tell me they thought I was throwing it all away.

“Your identity as a doctor is so entwined in your sense of self. While colleagues were generally incredibly supportive, it did reveal to me that there is shame attached.”

Vicky remains active in a Facebook group for medics looking for an alternative route through the profession. “It has thousands of members. Almost daily there’s an anonymous post from someone reporting their experience and saying ‘I don’t know what to do’, and I’ll jump in and say I’m very happy to talk. Without fail I’ll get four or five messages from other people saying, ‘I saw your post, can I please speak to you.’ The number of people getting in touch is staggering.”

A shared experience

In 2016, Vicky graduated from UQ with her master’s degree – where her thesis became the basis for the university’s student-based Mental Health Strategy – and she was struck by the “absolute brain shift” in moving from the medical model.

“You take information, you’re refining it, trying to come up with a differential diagnosis, you’re very much positioned as the expert. It’s a real brain shift to realise it’s not just about the information that you’re getting, it’s not that you’re the expert, because you’re very much not, but it’s just as much the process and the immediacy of what’s happening between you. It’s such a deeply respectful, shared experience. It’s amazing and such a privilege to be able to do that with people.”

Her approach to counselling involves first gauging the individual patient’s needs, and their hopes as to what counselling will provide.

“I often ask people if they have an idea of what they’re looking for. Sometimes they’re looking for strategies, sometimes they just want to talk and other times they want to figure out why they think the way they do,” Vicky says.

“There’s the solution-focused counselling approach, but I think it’s the deep respect for walking alongside someone in the knowledge you’re not there to come up with all the answers. I’m not the expert on their life but I’m facilitating them on their path of exploration.

“When we think about the contrast with medicine, we know that doctors whose patients like them are far less likely to be sued and, if you delve into that, it’s really about people wanting a personal connection. It’s not the person who prescribing antibiotics, it’s the person who makes you feel safe and heard. That’s the power of the interpersonal therapeutic alliance.”

Defining Counselling Part 2: A Practitioner's Approach

The pedestal effect

Originally from the UK (she completed her medical degree at the University of Birmingham) and then moving to Australia, Vicky has seen a notable difference in attitudes towards counselling between the two countries.

“Sadly, counselling is often undervalued in Australia – potentially due to its unregulated nature, potentially due to psychology positioning itself as expert, and potentially as Australia does not have such a rich and respected history of counselling and psychotherapy – unlike places like the UK, Europe or the US.”

One of the fractures in the way counsellors are seen stems from it being an unregulated profession.

That said, any step to raise the profile of counselling should be taken with careful consideration. She says there are both advantages and disadvantages to trying to get counsellors eligible for Medicare rebates – for instance: “I know many of my doctor clients are deeply suspicious of Australian Health Practitioner Regulation Agency–registered practitioners, due to the fear of mandatory reporting by treating practitioners.”

Nor is Vicky an advocate of counsellors moving into the area of other allied health professionals by performing diagnostic tests, for instance. “Absolutely we need to be more formalised as allied health professionals,” she says.

“But while the more formalised assessment processes used by psychologists are often positioned as a strength of psychology, counselling’s strength really relies on there being nowhere to hide. We are not reliant on trying to define someone’s experience according to their responses to assessment, but rather on seeing the person as a whole and helping the individual to explore that themselves, taking into consideration all the complex influences that make each individual who they are. We’re less about labelling and reductionist thinking and [more about] seeing the messy, complex whole of a person. I don’t believe counsellors do want to be performing diagnostic tests. There is a risk if you go too far down the traditional diagnostic route that it takes away the power of what counselling is all about.”

The unregulated nature of counselling in Australia creates something of a grey area that can only be policed by individuals. “Legally, ethically and morally, counsellors should not be practicing beyond their area of expertise,” says Vicky. “While some situations will be standardised – for example, legal requirements – others are likely to differ according to the individual counsellor’s experience and training.”

A long and winding road

Vicky uses the concept of ‘planned happenstance’ to describe her unexpected – and entirely rewarding – journey from medicine to counselling. A term used in careers counselling, it counters the traditional narrative of a career as a linear arc, starting at A and winding up at B.

“Particularly when you’re younger you think you need to know where you’re going and what your goal is. But planned happenstance is the idea that there’s real benefit to taking a meandering route, because not only will you gain experience along the way but also you’ll wind up at a place you could never have anticipated at the outset,” she says. “Me as an 18-year-old at med school in the UK could never have anticipated living in Brisbane in my 40s as a counsellor. All of my experiences have been really helpful, and I feel like I’m in the right place now.”

Defining and Driving the Counselling Profession: Part 1

Defining Counselling: Part 1 of 3, as featured in Vol 23 No 1 Autumn 2022 of the Counselling Australia Journal.

By Larissa Dubecki

When Dr Sophie Lea arrived for her first session as a school counsellor 20 years ago, she found she had been given the cleaner’s storage room as her clinical space.

“I remember it like yesterday. It really does show how they just weren’t understanding the requirements that we need as therapists in the school space,” she says. “I tried to liven it up by putting a pot plant in there and an Eminem poster to appeal to the kids. Not coincidentally, my PhD ended up being on therapeutic space design.”

A Monash University lecturer in Counselling, as well as an adolescent and family counsellor, teacher, education wellness consultant and clinical supervisor, Sophie has witnessed significant changes in the counselling space over the past two decades.

“It was very unusual back then for school systems to even have counsellors, and I could see it was all about having psychologists and being able to do diagnostics and funding applications,” she explains. She has encountered all the myths about counselling over her career – including the view that the counsellor’s job is to ‘fix’ the client – but has cause for optimism after witnessing the profession assert its place in the allied health services while maintaining its own important identity.

“For me the core driver is around the gift and responsibility and privilege of being able to support others in their mental wellness journeys,” she says. “Counselling is a dynamic and courageous exchange with people who are sometimes at their most vulnerable. In my opinion, counselling explores the ‘how’ and ‘why’ of human existence in a safe, accepting and supportive environment. As I say to my students, counselling is all about heads and hearts.”

Dr Sophie Lea on Defining Counselling

Photo: Penny Stephen

Counselling literacy

When differentiating counselling from other mental health professions to her students, Sophie asks them to envisage a triangle model.

“I place counsellors at the base of that triangle: we support clients with a wide variety of client issues such as relationships, aspirations of self-actualisation and, of course, mental health and wellbeing. Moving up the triangle, the client intervention becomes more specialised, with social workers and psychologists providing more targeted interventions, assessment and, when required, diagnosis. Finally, at the top of the triangle, we sit in the medical model, with psychiatrists and doctors able to assess and prescribe medication or referral to specialist in-patient settings for clients who require it. But there’s fluidity in that too; health care professionals may have training and experience on more than one level.”

She also draws a distinction between counselling and psychotherapy. “In my experience, the clear definition of counselling and psychotherapy has at times seemed murky – partly because some therapists, such as myself, would view them as interchangeable. The simple distinction I make is that counselling is usually more short-term in its intervention, it supports clients with conscious events and emotions and has a present-day orientation and impact; I see it as more pragmatic in its design. Whereas psychotherapy is a deeper exploration of a client’s life experience, it encourages further self-awareness and understanding of more entrenched patterns of behaviour and delves into uncovering unconscious understanding that empowers the client to facilitate lasting change.”

The road to accreditation

For Sophie and many of her students, counselling is a deliberate choice over psychology. “There is not just depth but also breadth to the work we do, which is one of the reasons I love the work so much,” she says.

A growing awareness and appreciation of counselling as an important part of allied health services is a heartening development for Sophie, but she finds all too often her Master of Counselling students are surprised that anyone in Australia can call themselves a counsellor.

“The lack of regulation in the counselling profession has created such a disservice to our profession over many years. It is something many counsellors have grappled with and been frustrated by. I am very grateful to have a membership to a counselling registration body, ACA, which sets required standards and champions our profession.”

The mental health burden of the pandemic on top of the complexity of the modern era – the corrosive effects of social media, for instance – has added weight to ACA’s call for qualified counsellors and psychotherapists to be included in the nation’s Medicare Benefits Schedule.

“The short-sightedness is what gets me,” says Sophie. “We have people who need support, who are suffering, and who don’t have the means to go private. The bottom line is it’s about humanistic intervention and support. It’s about the responsibility of putting our profession in a space where it’s recognised. There’s also the critical responsibility of doing no harm to our clients … how can we guarantee that without adequate training and being able to adhere to ethical and professional guidelines? It’s a no-brainer for me and it’s completely antiquated.”

Jim Schirmer (pictured), an associate lecturer with the University of Queensland whose research specialises in the professional identity of counsellors and counselling, argues that an advanced mental health system would recognise the complementary strengths of the range of professions involved. “In such a system, I think counselling would bring some distinctive theoretical, philosophical and practical strengths,” he says. “Practically, counsellors not only deal with mental illness, but also are particularly well-trained in non-pathological areas of human difficulty. When I compare counselling training programs to other mental health and human service professions, counselling training includes not only mental health, but also common areas such as grief and loss, relationships and families, crisis counselling, domestic violence and health. In this way, counsellors have the capacity to see clients across a very broad range of human needs.”

Jim Schirmer on Defining Counselling

Photo: University of Queensland

Clinical applications

This raises the question: should counsellors play a role in hospital and emergency department settings – and conduct diagnostic tests if they are appropriately trained?

For Sophie, the integration of counselling services in healthcare settings makes perfect sense in light of the current mental health crisis. “I think counsellors could play a vital role in this area, triaging clients and working alongside healthcare professionals to reduce the current demand for mental health services and implement much-needed mental health support in a timely manner,” she says. “With the current pandemic, I remain concerned about the wait times clients are experiencing to be able to see allied health professionals. It’s unacceptable, particularly when there are thousands of qualified and experienced counsellors willing and able to play a part in supporting our community.”

Jim, however, cautions that formal diagnostic measures and tests might be at odds with the humanistic strengths of counselling.

“If the question is whether counsellors could conduct formal diagnostic tests, the answer would be a qualified yes. Currently, counsellors are rarely trained to conduct such assessments, but there would be no reason at all why they couldn’t be trained and assessed as competent in any formal diagnostic measure,” he says. “A diagnostic assessment can be valuable for its ability to provide a valid counterbalance to the counsellor’s subjective judgements, as a system-recognised means of accessing support, and as a validating experience for the client’s distress. That said, there are also several arguments for the limitation of diagnosis. Humanistic therapies would caution us from any reductionist account of our clients’ experiences and postmodern therapies would remind us that any discourse is only one socially constructed version of reality. More broadly, though, there would be forms of helping that would be beyond our definition. Something may be helpful or therapeutic but still not be practiced by counsellors. Psychiatric medication would be an obvious example of this. Similarly, a musician or a remedial masseuse may bring about therapeutic ends, but we would not call them counsellors. Therefore, counsellors should be proud of their broad and effective scope of practice, but also happy to know the limits of this and be willing to acknowledge the therapeutic work that others do.”

To the future

Ask Sophie where she would like to see the counselling profession in five years’ time and the answer is simple: “I’d love us to be regulated, number one. I’d love governmental systems to be able to recognise the important role we can play in supporting us through and around these trying times globally … that we have a really strong skillset to offer.”

So how is that achieved? Further resourcing in this space is crucial, enabling clients to access services in a variety of ways that might suit their individual requirements: “Not just in cities but in regional areas as well. Let’s think about the telehealth space and how we can appropriately facilitate that, let’s think about psychotherapists, let’s think about creative arts therapists and animal-assisted therapy as well as counsellors – those different delineations of therapeutic support and intervention.”

Overall, she hopes to see the counselling profession continue to commit to its professional standards and responsibilities, guided by a scope of practice and ethical guidelines, and not lose sight of the expert skill sets counsellors have in facilitating a safe and purposeful therapeutic relationship with a diverse range of clients.

“That’s where I’d love to see our profession heading and I think we have the training opportunities, experience and passion to do it.”

Reframing Autism and Understanding the Female Autism Phenotype

Article from: Counselling Australia Journal: Volume 22: Number 3 – Spring 2021

By Dr Jillian Stansfield

The Diagnostic and statistical manual of mental disorders (DSM-5), published in 2013, refers to autism spectrum disorder (ASD) as an umbrella term and is based on a deficit medical model. The DSM-5 diagnosis of ASD includes the previously separated diagnoses Asperger’s syndrome, Rhett syndrome, pervasive developmental disorder and pervasive developmental disorder not otherwise specified (PDD-NOS), and focuses on traits most often associated with males. The criteria to be met for an ASD diagnosis under the DSM-5 are persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following: socialemotional reciprocity; non-verbal communicative behaviours; and developing, maintaining and understanding relationships (APA, 2013). These symptoms are present from early childhood and limit or impair everyday functioning (APA, 2013). A diagnosis of ASD is also assigned a severity specifier of level 1, 2 or 3, depending on the support required. Therefore, the terms ‘high-functioning’ and ‘lowfunctioning’ are redundant and are not included in either of the diagnostic manuals DSM-5 or International Classification of Diseases (ICD-11) (World Health Organization, 2018). As there is no definitive biological test for determining autism, a process is followed that relies on multiple sources of information, including tests and observations to assist medical professionals with making a diagnosis (APA, 2013).

Diagnoses of females are predicated on the same narrow ASD criteria, which is geared towards the male presentation of autism and is one reason why girls may not receive an autism diagnosis, also referred to as a ‘missed diagnosis’ (Fields, 2020; Stansfield, 2020). A ‘misdiagnosis’ can occur when someone is diagnosed with a mental disorder based on a cluster of traits that overlap with autism. The lack of understanding and research about the female-typical presentation or female autism phenotype is reflected in the disparity of diagnoses between males and females, a ratio of 4:1 (Hull et al., 2020).

However, the use of one term, ‘autism’, has resulted in confusion about where people diagnosed under the range of autistic-like conditions should be placed along the autism spectrum (Bennett & Goodall, 2016). This is particularly problematic when individuals are overlooked or misdiagnosed, particularly females, or when the preconceived view is that the overarching diagnostic term is ‘Kanner-type’ or ‘classic’ autism traits. The words ‘disability’ and ‘disorder’, both of which are used in social discourse, indicate a deficit in ability or that something is wrong. However, some autism deficits could be viewed as strengths or advantages (Goodall, 2015). There is an inconsistency in language about and definitions of autism (Cleaton & Kirby, 2018).

Instead of being considered a disability or disorder, as the formal terms suggest, autism is regarded by some as more of a neurological difference (Goodall, 2015). Throughout this paper, the terms ‘autistic’ and ‘on the autism spectrum’ are preferred when referring to a person diagnosed with an autism spectrum disorder. Neither a ‘person-first’ nor an ‘autism-first’ approach is used because some people in the autism community prefer one term over the other and it is essential for the terms adopted to respect the autistic community (Kenny et al., 2015).

History of autism

The history of autism is confronting, with an evolving line of thought that includes many misconceptions and perspectives: from perceptions that people on the autism spectrum have ‘refrigerator mothers’, to people being labelled as ‘rain man’ or as having an ‘extreme male brain’ (Silberman, 2015). Due to the pathologising of traits and to stigma, today’s knowledge and understanding of autism is still in its infancy and it appears people are some way off from understanding and accepting this different way of thinking (Stansfield, 2020).

Child psychiatrist Leo Kanner identified the ‘classic’ model of autism towards the middle half of the last century (Kanner, 1943, 1944; Silberman, 2015; Singer, 2017). Kanner used the term ‘autism’ from the Greek word for self (autos) to describe this cluster of traits, as these children “seemed happiest in isolation” (Silberman, 2015, p. 5).

At the same time, Asperger’s syndrome, commonly known as Asperger’s, was first identified by Dr Hans Asperger, who noted some similar characteristics among children in his paediatric practice (Attwood, 2004; Silberman, 2015). Although Asperger referred to his patients as “little professors” due to their abilities in math and science (Silberman, 2015, p. 6), this more positive aspect of his work is tainted by his link to the Nazi era: he is said to have been among the doctors who had the power to decide the fate of children who did not meet certain physical and mental abilities (Sheffer, 2018; Szalai, 2018). Although the origin of autism and the term ‘Asperger’s syndrome’ are tainted by this unsavoury narrative, Asperger’s work was the starting point for discourse on autism (Stansfield, 2020).

When Lorna Wing, a psychiatrist, had a daughter who was diagnosed with Kanner’s classic autism in the 1960s, it was almost unheard of for a female to receive an autism diagnosis. Following the realisation that her daughter had autism, Wing made it her quest to seek out the supports available to families of children like her own (Silberman, 2015). Wing (1981) found that many children did not fit the mould of Kanner’s rigid traits and set out to expand the definition of autism, proposing that it was a ‘continuum’ and later adopting the term ‘spectrum’ (Silberman, 2015, p. 353). Despite Wing’s work, several decades later the connection between autism and girls remains relatively undiscovered and far more is known about autism in males (Tomlinson et al., 2020).

Background of autism spectrum disorder

The DSM-5 is becoming a somewhat outdated source for determining a diagnosis, and controversy surrounds the umbrella term ‘autism spectrum disorder’ in the last update. One point of contention is the use of the word ‘disorder’, because autism is becoming more accepted, particularly in the autistic community, as a neurotype or condition rather than as a mental disorder (Stansfield, 2020). The view that autism is a disorder that can be cured is reflective of the medical model approach, and lags behind anecdotal and clinical observations of the female autism phenotype (Marshall, 2014). No specific changes appear to have been made to DSM-5 diagnostic criteria to reflect this in the foreseeable future.

Silberman (2015) posed the question, “[A]fter 70 years of research on autism, why do we still seem to know so little about it?” (p. 15). People on the autism spectrum are beginning to demonstrate that ‘‘‘neurotypical’ is not the only way to be, or even the best way to be” (Singer, 2017, p. 1195). Over time, autism has become recognised more as a neurotype (neurological type) that differs from a ‘neurotypical’ brain, which is a dominant neurotype, and which Singer observes is “a term coined to sideline [people, like] the word ‘normal’” (2017, p. 404). Neither one is better or worse than the other; the neurotypical brain is “designed to facilitate socialisation” and the autistic brain is designed “to focus on understanding the world around us” (Castellon, 2020, p. 31).

The cluster of deficit-based traits for ASD identified in the DSM-5 are oriented toward males (Ranson & Byrne, 2014), leaving girls undiagnosed or misdiagnosed when their collective autistic traits are misinterpreted and categorised as a mental illness rather than as autism (Carpenter et al., 2019). According to the traditional definition of autism, identified as a male syndrome, the number of children diagnosed with ASD has risen over the last decade (Sproston et al., 2017). The higher rate of diagnoses does not mean the number of people who have been born with the condition has risen; rather, it is illustrative of a better understanding of autism due to ongoing research, education and awareness (Carpenter, 2017). Further research on girls and autism is likely to see the number of female diagnoses increase, shrinking the gap between males and females.

The lack of knowledge about girls and autism due to a dearth of research leaves many girls unsupported, misdiagnosed and misunderstood, even though they may receive a diagnosis as an adult (Carpenter et al., 2019; Cook et al., 2017; Mademtzi et al., 2017). The later diagnoses of women may be one reason why ASD is, according to statistics, diagnosed four times more often in males than in females. Other reasons include ASD presenting differently in males (APA, 2013; Mademtzi et al., 2017; Moyse & Porter, 2015) and diagnostic tools derived from the DSM-5 being skewed towards male traits and characteristics of autism (Ranson & Byrne, 2014). A further reason frequently cited for missed or late diagnoses in females is their ability to mask traits associated with autism (Cook et al., 2017; Ranson & Byrne, 2014). Females are better at masking or camouflaging their symptoms through strategies such as mimicking and scripting (Myles et al., 2019). Due to being able to mask their inadequacies and mimic others, females on the autism spectrum are perceived as ‘normal’, with the result that many autistic girls ‘fly under the radar’ and suffer in silence during their primary years (Attwood, 2006).

Social model and medical model of disability

The medical model versus social model debate is frequently highlighted in the literature on autism (Alsharif, 2019; Liu et al., 2018; Manago et al., 2017; Pickard, 2019; Singer, 2017) and is included in this overview to acknowledge how far our thinking has come in terms of what autism is or is not and how it presents in everyday life. The medical model, with a deficit focus on ASD according to the DSM-5, insinuates a stigma associated with the term ‘disorder’: that it is something ‘wrong’ that requires ‘fixing’, even when the perceived negatives could be strengths or unique abilities (Angulo-Jiménez & DeThorne, 2019).

The social model proposes more than one perspective, but essentially asserts that autism is a social construct whereby society determines what is a disability and ability and how they are approached (Mitra, 2006).

The social and medical models are in opposition to one another – the latter focuses purely on disability, whereas the social model draws attention to autism as a spectrum and showcases abilities. Although the social model exposes the social inequalities encountered by people on the autism spectrum, it acknowledges that it is not the person with the disability who needs to change, but society that needs to change its perspectives on autism (Shakespeare & Watson, 2002).

The neurodiversity paradigm for understanding autism is sometimes considered an ‘outgrowth’ of the social model in that it acknowledges the need for support (Angulo-Jiménez & DeThorne, 2019, p. 570).

Disassociating autism from the notion of being a mental disorder and moving towards a more holistic view of how it manifests in the real world means that the strengths inherent in this different way of thinking are not ignored. A different way of thinking simply means autistic people will learn about the world in a different way (Sherratt, 2005).

What the medical model identifies as deficits, the social model may identify as strengths. Focusing on a social model, whereby autism is identified as a neurology, will enable a better understanding of autism in females, not only in a schooling context, but also in the medical milieu where diagnosis takes place. This holistic view of autistic strengths and challenges, rather than just deficits, will allow for better understanding and earlier identification of females on the autism spectrum.

Mediation is needed between the social and medical models to reframe how society views disability, reduce stigma and promote acceptance. One model that is emerging from this binary view is the neurodiversity paradigm, which stems from the social model (den Houting, 2019). Singer (2017) is credited with coining the term ‘neurodiversity’, and did so in the belief that “we need to go beyond the dichotomy of the medical model vs. social model” (p. 615).

Given the history of autism, the medical and social models, people’s lived experiences and the adoption of the term ‘neurodiversity’ within autism discourse, Silberman’s (2015) modern view of autism as a “different operating system” is a favourable one (p. 471). The neurodiversity paradigm began to emerge in the late 1990s (Angulo-Jiménez & Dethorne, 2019; Silberman, 2015) to explain the concept that there is not just one type of ‘normal’ brain.

Identifying the female autism phenotype

As girls on the autism spectrum grow older, they are more likely to be misdiagnosed with mental health issues (Myles et al., 2019). Misdiagnosis can have devastating long-term effects, as undiagnosed females may be medicated, develop limited survival strategies and are often left to navigate a challenging world as ‘misunderstood’ individuals, leading to a plethora of problems in their adulthood (Holliday Willey, 2012). Teachers are often the first to recognise when a student may need a referral to a specialist health professional so that these students receive the appropriate support and intervention in the early years.

As autistic females are underrepresented in the research, ‘female stories’ are often shared to gain insights (Jarman & Rayner, 2015). Jarman and Rayner presented themselves as case studies and shared their personal stories and knowledge of being on the autism spectrum. Temple Grandin’s Asperger’s and girls (2006) and Wenn Lawson’s Girls and autism: Educational, family and personal perspectives (2019) are examples of the autistic voice. They highlight the importance of listening to the voices of autistic females by adding an element of authenticity to the academic discourse. There are also well-known autistic women presented in the media, Greta Thunberg (Swedish environmental activist), Susan Boyle (Scottish singer) and Hannah Gadsby (Australian comedian) who openly share their diagnosis and talents, and challenge ideas of what autism ‘looks like’. Jarman (2013) proposed further case studies on school-aged females on the autism spectrum to enhance understanding and recognise their unique challenges and characteristics. As research often lags behind clinical and anecdotal observations (Marshall, 2015), Jarman’s (2013) work was important for advancing our understanding of the relatively new medical term ASD.

There are many anecdotal and clinical observations on the female profile of autism in the form of checklists and online stories about ‘lived experiences’. These can be a resource for females who have been misdiagnosed, have a missed diagnosis or are seeking answers to explain their differences (Craft, 2016; Marshall, 2016; Starlight and Stories, 2018; The Little Black Duck, 2018). Tania Marshall is an Australian psychologist, specialist and prolific writer on autistic girls and women, who has published numerous books and blogs on the female presentation of autism, including I am Aspien Girl and I am Aspien Woman. Marshall (2019) explored the many traits of girls on the autism spectrum, as well as themes such as masking, anxiety, perfectionism, emotion and high achievement, acknowledging that many of these traits make it difficult to identify and support autistic females.

A communication tool, CASSIE, was recently developed from evidence-based research, and focused on the female autism phenotype in the early years of schooling (5–8 years of age). The CASSIE tool, which is presented in the form of a wheel, can assist with identifying autistic girls in the early years’ classroom and help teachers to better manage girls’ learning and social experiences (Stansfield, 2020). The CASSIE tool further informs the literature about the traits and characteristics that pertain to the female autism phenotype. There is no single way to categorise the traits and characteristics of girls on the autism spectrum, and CASSIE incorporates communication, academic, sensory, social and identity aspects (Stansfield, 2020). Stansfield (2020) found several reasons why girls are ‘invisible’, meaning fewer girls are diagnosed than boys: they have masking traits; they are social, but more so with adults; traits vary between males and females; they are capable but this is not always shown in their work; there are misconceptions that autism is a ‘boy’ condition; and deficits are seen as strengths and vice versa. These reasons support the DSM-5 (2013), which states that females go unrecognised due to “subtler manifestations of social and communication difficulties” (APA, 2013, p. 57).

The development of the CASSIE tool is beneficial not only to teachers and parents, but also to the wider support network. It can help identify autistic females and support them, regardless of whether they are diagnosed (Stansfield, 2020). Ongoing research on the female autism phenotype, such as the contributions of Jarman (2013) and Stansfield (2020), may assist in reducing the number of missed diagnoses or misdiagnoses of autistic females.

Conclusion

There is a continuing need for acceptance of autism in the general community. Sharing knowledge brings about greater understanding, and highlighting the female autism phenotype with a focus on strengths is a positive way of reducing stigma and increasing acceptance. Over time, education will change community perspectives on autism and how it presents in females. People on the autism spectrum are beginning to demonstrate that “‘neurotypical’ is not the only way to be, or even the best way to be” (Singer, 2017, p. 1195). Over time, autism has become more recognised as a neurotype that differs from a neurotypical brain, a dominant neurotype (Singer, 2017). Neither one is better or worse than the other.

 

References 

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association 

Alsharif, H. N. (2019). The model of disability in Saudi Arabia [Article]. Indonesian Journal of International and Comparative Law, 6(1), 3-23. 

Angulo-Jiménez, H., & DeThorne, L. (2019). Narratives About Autism: An Analysis of YouTube Videos by Individuals Who Self-Identify as Autistic. American Journal of Speech-language pathology, 28(2), 569-590. https://doi:10.1044/2018_AJSLP-18-0045 

Attwood, T. (2004). Strategies to reduce the bullying of young children with Asperger’s syndrome. Australian Journal of Early Childhood, 29(3), 15-23. 

Attwood, T. (2006). The Pattern of Abilities and Development of Girls with Asperger’s Syndrome. In T. Attwood., T. Grandin., T. Bolick., C. Faherty., L. Iland., J. McIlwee Myers., R. Snyder., S. Wagner, & M. Wrobel (Eds.) Asperger’s and girls, (pp.82-172). Future Horizons. 

Bennett, M., & Goodall, E. (2016). A Meta-analysis of DSM-5 Autism Diagnoses in Relation to DSM-IV and DSM-IV-TR [journal article]. Review Journal of Autism and Developmental Disorders, 3(2), 119-124. https://doi.org/10.1007/s40489-016-0070-4 

Carpenter, L. (2017). Supporting students with Autism Spectrum Disorder. In M. Hyde., L. Carpenter., & S. Dole (Eds.) Diversity, inclusion and engagement. (3rd ed., pp.284-307). Oxford University Press. 

Carpenter, B., Happé, F., & Egerton, J. (2019). Where are all the autistic girls? In Carpenter, B., Happé, F., & Egerton, J. (Eds) Girls and autism. Educational, family and personal perspectives. (p.3-9). Routledge. 

Castellon, S. (2020). The spectrum girls’ survival guide. Jessica Kingsley Publishers. 

Cleaton, M., & Kirby, A. (2018). Why Do We Find it so Hard to Calculate the Burden of Neurodevelopmental Disorders? Journal of Childhood and Developmental Disorders, 4(3:10), 1-20. 

Cook, A., Ogden, J., & Winstone, N. (2017). Friendship motivations, challenges and the role of masking for girls with autism in contrasting school settings. European Journal of Special Needs Education, 33(3), 302-315. 

Craft, S. (2016). Females with Asperger’s Syndrome Checklist by Samantha Craft. https://everydayaspie.wordpress.com/2016/05/02/females-with-aspergers-syndrome-checklist-by-samantha-craft/ 

den Houting, J. (2019). Neurodiversity: An insider’s perspective. Autism, 23(2), 271–273. https://doi.org/10.1177/13623 61318 82076 2. 

Fields, L. (2020). Adult autism: hidden in plain sight. Readers Digest Magazine, April 2020, 46-49 

Goodall, C. (2015). How do we create ASD‐friendly schools? A dilemma of placement. Support for Learning, 30(4), 305-326. https://doi:10.1111/1467-9604.12104 

Holliday Willey, L. (2012). Safety skills for Asperger women: How to save a perfectly good female life. Jessica Kingsley Publishers.  

Hull, L., Petrides, K. V., & Mandy, W. (2020). The Female Autism Phenotype and Camouflaging: a Narrative Review. Review Journal of Autism and Developmental Disorders. doi:10.1007/s40489-020-00197-9 

Jarman, B. C. (2013). The School Experiences of Females with Asperger’s Syndrome: The recollection of adults and perspectives of parents. [Master of Education with Honours Dissertation]. University of Tasmania. TROVE database. 

Jarman, B., & Rayner, C. (2015). Asperger’s and Girls: What Teachers Need to Know. Australian Journal of Teacher Education, 39(2), 128 -142. https://doi:10.1017/jse.2015.7 

Kenny, L., Hattersley, C., Molins, B., Buckley, C., Povey, C., & Pellicano, E. (2016). Which terms should be used to describe autism? Perspectives from the UK autism community. Autism, 20(4), 1-21. 

Liu, M. J., Ma, L. Y., Chou, W. J., Chen, Y. M., Liu, T. L., Hsiao, R. C., Hu, H.F., Yen, C. F. (2018). Effects of theory of mind performance training on reducing bullying involvement in children and adolescents with high-functioning autism spectrum disorder. PLoS ONE, 13(1). https://doi:10.1371/journal.pone.0191271 

Mademtzi, M., Singh, P., Shic, F., & Koenig, K. (2017). Challenges of Females with Autism: A Parental Perspective. Journal of Autism and Developmental Disorders. doi:10.1007/s10803-017-3341-8 

Manago, B., Davis, J. L., & Goar, C. (2017). Discourse in Action: Parents’ use of medical and social models to resist disability stigma [Article]. Social Science and Medicine, 184, 169-177. https://doi.org/10.1016/j.socscimed.2017.05.015  

Marshall, T. (2019). Teaching girls with autism. https://senmagazine.co.uk/home/articles/senarticles-2/teaching-girls-with-autism 

Marshall, T. A. (2014). I am Aspien girl. Tanya A. Marshall. 

Marshall, T. (2013, 2016). First Signs of Aspergers in Bright Young Girls Pre-School. https://taniaannmarshall.wordpress.com/2013/06/22/first-signs-of-asperger-syndrome-in-young-girls-pre-school/ 

Mitra, S. S. S. (2006). The capability approach and disability. Journal of Disability Policy Studies, 16(4), 236-247.  

Moyse, R., & Porter, J. (2015). The experience of the hidden curriculum for autistic girls at mainstream primary schools. European Journal of Special Needs Education, 30(2), 187-201. https://doi:10.1080/08856257.2014.986915 

Myles, O., Boyle, C., & Richards, A. (2019) The social experiences and sense of belonging in adolescent females with autism in mainstream school. Educational and Child Psychology, 36, 8-21 

Ranson, N., & Byrne, M. (2014). Promoting Peer Acceptance of Females with Higher-functioning Autism in a Mainstream Education Setting: A Replication and Extension of the Effects of an Autism Anti-Stigma Program. Journal of Autism and Developmental Disorders, 44(11), 2778-2796. https://doi:10.1007/s10803-014-2139-1 

Sheffer, E. (2018). Asperger’s children: The origins of autism in Nazi Vienna. New York: Norton, W.W. & Company, Inc. 

Shakespeare, T., & Watson, N. (2002). The social model of disability: an outdated ideology? ‘Research in Social Science and Disability, 2, 9-28.  

Silberman, S. (2015). Neurotribes: the legacy of autism and the future of neurodiversity. Penguin Random House LLC. 

Singer, J. (2017). Neurodiversity: The birth of an idea. 

Sproston, K., Sedgewick, F., & Crane, L. (2017). Autistic girls and school exclusion: Perspectives of students and their parents. Autism and Developmental Language Impairments, 2, 1-14. https://doi:10.1177/2396941517706172 

Stansfield, J. (2020). Alannah, Bree and CASSIE: The ABC of girls on the Autism Spectrum in early years classrooms. https://ro.ecu.edu.au/theses/2376 

Starlight and Stories. (2018). Girls with Autism: How Do We Spot Them? Starlight and Stories. https://starlightandstories.com/2018/02/01/girls-autism-spot/ 

Szalai, J. (2018). Once viewed as a saviour of children, Hans Asperger is now called a Nazi collaborator. The New York Times. https://www.nytimes.com/2018/05/09/books/review-aspergers-children-autism-nazi-vienna-edith-sheffer.html 

The Little Black Duck. (2018). Females on the Autism Spectrum. The Little Black Duck. https://www.thelittleblackduck.com.au/product/females-on-the-autism-spectrum-new/ 

Tomlinson, C., Bond, C., & Hebron, J. (2020). The school experiences of autistic girls and adolescents: a systematic review. European Journal of Special Needs Education, 35(2), 203-219. doi:10.1080/08856257.2019.1643154 

Wing, L. (1981). Asperger’s syndrome: A clinical account. Psychological Medicine,11(1), 115-129. doi:10.1017/S0033291700053332 

World Health Organisation (WHO). (2018). Classifications: ICD-11 is here. Classifications. https://www.who.int/classifications/icd/en/ 

Suicide Prevention: Lessons for Counsellors

Article from: Counselling Australia Journal: Volume 23: Number 2 – Winter 2022

By Melissa Marino

Counsellors are critical gatekeepers in the prevention of suicide, says Dr Nicole Hill, a leader in youth suicide prevention research in Australia.

It is, therefore, integral they and other health professionals receive suicide-specific training and operate as part of a healthcare network with families, educators, community organisations and social systems to identify risk and respond in a timely manner.

Dr Hill says her work shows that one in two young people who die by suicide had a suspected or known mental health diagnosis at their time of death. This is important for counsellors to know as it indicates there are opportunities within the health system to make a difference.

The initial response someone receives when reaching out for help can determine how likely they will be to seek future support, she says. With often weeks-long waiting lists for therapy, it is critical that adequate interim support and information is provided to keep people engaged.

“There’s a duty of care to inform young people of strategies or resources they can use to help bridge that waiting period,” she says.

Crisis helplines, such as Lifeline, “can really help during the fleeting suicidal crisis”, she says. And new peer support programs such as one being trialled by SANE Australia could be valuable.

For young people who have disclosed suicide ideation and have a specific plan, best-practice strategies such as means-restriction counselling and safety planning can be very effective. “The research shows that in the general population, safety planning can reduce the risk of suicidal behaviour by up to 50 per cent – so that’s a really important one,” she says.

Culturally informed care is also critical to ensure LGBTIQA+ young people and others who are marginalised have a safe space to go, she says. “It’s as much about addressing the mental health concerns of young people as the social and cultural contexts and stresses that they face.”

Training more counsellors would help address the issue of mental health in young people but, in the long term, changes to the system to ensure young people could access coordinated, ongoing support are required,  she said.

As a keynote speaker at the International Association for Suicide Prevention conference, Dr Hill says such events are important for upskilling, exchanging ideas and learning about evidence-based best practice. On a personal level, it is also invaluable to meet others working in the “significantly underfunded” yet critical field,  she says.

“The work is hard. We’re dealing with suicide, which is a very difficult topic and has a personal cost. But being able to connect with others who are dealing with the same challenges is really good for our own wellbeing as well.”

Mental wellness in a time of crisis recovery

Article from: Counselling Australia Journal: Volume 23: Number 2 – Winter 2022

By Melissa Marino 

Professor Sam Harvey

Over the past 20 years in Australia, great gains have been made in public health outcomes; however, mental wellbeing is a notable exception. As the COVID-19 pandemic shines a spotlight on mental health, Black Dog Institute executive director Professor Sam Harvey shares his insights on how we can start to rectify this – and the critical role counsellors will play.

As the executive director of Black Dog Institute, Professor Sam Harvey leads research and on-the-ground programs to understand, treat and prevent mental illness. On a personal level, he keeps on top of his own mental health through a few simple activities. “Spending time with my kids, going out for a walk – they are really important to me so I make sure they’re prioritised,” he says.

His advice to others seeking to maintain their own wellbeing is to recognise the specific activities that matter to them – and to take the time out to do them. “As individuals, taking action is how we can help our own mental health,” he says.

For Professor Harvey, the COVID-19 pandemic and the lockdowns that came with it provided a better balance between work and home life and more time for the activities he enjoys.

But for many others, the experience was the opposite. Home schooling was much harder in smaller dwellings with fewer computers. And many people in the lowest-paid, least-secure jobs either lost employment or were unable to work from home.

The effect of changed working conditions under COVID-19 on people’s mental health was so significant, Black Dog Institute produced a white paper on the issue. “COVID disproportionately affected those who were least able to take another hit,” says Professor Harvey. “And it’s something we really need to keep an eye on because we know the mental health consequences of insecure work are very substantial.”

Shadow pandemic

Increased reports of depression, anxiety and eating disorders are all symptoms of what has been coined a ‘shadow pandemic’ of mental ill-heath playing out in the wake of COVID-19.

By amplifying social disadvantage, the pandemic has propelled trends that have been a long time building, making mental ill-health one of the dominant health problems in society today.

In Australia, mental health symptoms are now the number one cause for people consulting with their GP, Professor Harvey says. And suicide has overtaken motor vehicle accidents as the leading cause of death among young people.

Unlike other major public health issues that have trended down over time, rates of mental health symptoms, particularly among young people, are increasing year on year, he says.

“This is particularly damning because since the industrial revolution, by and large, we have handed over better health outcomes to future generations – for example in cardiovascular disease and lung health,” he says. “The two areas in which we’ve failed are obesity and mental health. They’re the two that are getting worse in the next generation, and we don’t understand why.”

As the relatively new executive director of Black Dog Institute (since November 2021) this is an issue Professor Harvey wants to understand and reverse. “It’s a huge unanswered question,” he says.

Golden opportunity

What is known is that increased rates of mental ill-health have corresponded with increased awareness of the issue – with both peaking in the pandemic.

If there is any silver lining, this heightened awareness opens a window of opportunity to address mental health meaningfully, says Professor Harvey, who is also the Institute’s chief scientist.

“As a community and at policymaker level, there’s an understanding of just what a big issue mental health is, and my key concern is that we don’t miss that opportunity with small-scale, ineffective interventions,” he says. “We have to use this moment to do things properly.”

For Professor Harvey, the right approach starts with increased funding. “We’ve underinvested in the past. And given that mental health is one of the most pressing health issues for society, an inadequate proportion of the budget at all levels of government goes towards it.”

Secondly, the funding must back evidence-based, coordinated programs and services around prevention, early intervention and treatment, he says. And COVID-19 has provided a blueprint for how science can guide such a response to a widespread, urgent public health issue.

“We mobilised the scientific community to answer the big questions and the people making decisions were guided by that science,” he says. “We need exactly that to happen with mental health. And the solution doesn’t lie just within the health settings. We have to do the right things in schools, in workplaces and in communities.”

Support structures

Schools and workplaces across Australia are full of good intentions to raise awareness around mental health, he says. But without adequate, science-backed resources to support them, they could be doing more harm than good.

“By just telling people about symptoms [of depression or anxiety] without giving them any practical skills to deal with them, without making sure there are services that can actually help, you risk at best wasting a lot of money and good intentions on something that’s not helpful,” he says. “And at worst, without offering any practical assistance, you may cause people to be more distressed than they would have been otherwise.”

Instead, he says, if programs such as those based around cognitive behavioural therapy, for example, were used in schools, initial distress could be prevented from developing into a more severe mental health problem.

To investigate the impact of adequate support structures, Black Dog Institute is embarking on research with a group of workers identified at increased risk of mental ill-health. It is screening emergency service workers to identify those who are at risk or unwell, and test whether their outcomes can be improved by having a range of health professionals, including counsellors, on hand.

“The reality is we’ve never been able to show the benefit of that support before, so this is a big step for us,” he says.

Coordinated workforce

Professor Harvey says a larger, better-funded and more coordinated mental health workforce is critical to ensure people get assistance when they need it. “There’s a lot of promotion encouraging people to get help when they have symptoms – which is fantastic – but let’s make sure when they see a doctor or counsellor or psychiatrist, they’re not left on a 12-month waiting list,” he says.

Wait times of this length are ludicrous, he says, and ultimately Australia needs to train a bigger workforce to meet demand. In the interim, in a lesson learnt through the rise in telehealth consultations over lockdowns, the existing workforce could be used more efficiently by blending online and face-to-face care.

Technology could also help address the fragmentation of mental health care that Professor Harvey says has become more pronounced over the past decade. If people could access their information, for example, they could share it between counsellors and other health professionals and “move more seamlessly between services to receive the support they need depending on how their symptoms are progressing”.

Counsellors, he says, will play a critical role in a better coordinated pool of mental health professionals supporting people’s changing needs.

“We need more counsellors, but we also need them to be properly integrated into the other parts of the health service, such as general practice,” he says. “There needs to be more of a focus funding collaborative care that brings everybody together rather than individuals operating in isolation.”

Evidence from Europe and the US shows that when you do collaborative care well, clients have improved outcomes and, overall, the costs are less. In Australia, coordination is challenging because of its mix of state and federal government and public and private sector providers. But it’s a challenge that must be tackled, he says. “Given the size of the problem, I just don’t think it’s optional anymore.”

Holistic support

Not a week goes by at Black Dog Institute without a parent or individual seeking help to navigate the system, he says. And there has also been a surge in schools and workplaces asking for advice around how to manage the distress and mental health challenges presenting in students and staff.

Leading Australia’s mental health response through schools, workplaces and communities is one of four key priorities in Black Dog Institute’s new five-year strategy. Another is developing new models of blended care to get optimal, tailored treatment to individuals.

“We want to make sure that mental health and wellbeing is front and centre when we think about what a post-COVID recovery looks like, making sure that as we return to some form of normality, we prioritise mental health in the way we set up our workplaces, schools and clinical settings.”

In workplaces, training for managers to spot when someone may be struggling is showing a way forward. “We’ve done large, controlled studies demonstrating that this type of intervention has a return on investment of A$10 saved for every dollar spent on the training because of the reduction in sickness absence among workers,” he says.

The wellbeing of those working in the sector is also a focus, with the Institute researching why health professionals have elevated rates of mental health symptoms and an increased risk of suicide.

The Institute also provides a national clinical service for health professionals, as well as training programs, resources and networks to manage burnout and promote mental health and wellbeing.

Prevention frontier

In schools, Institute research is underway with primary-aged children on how to reliably identify those who may be struggling and help alter their trajectory. “We now know you can see clear signs of anxiety when children are in primary school. And that’s important because it’s much easier to treat the problems when their minds are more flexible,” Professor Harvey says. “If you leave it until they’re older, it becomes harder to shift.”

There are also promising developments in early intervention for adults, he says. Institute research from 2021 shows that the number of stressed workers who went on to develop depression was reduced through the use of a smartphone app featuring activities to develop mental fitness and resilience.

“There’s a range of exciting opportunities around prevention that we’re now trying to demonstrate can work broadly,” he says.

Prevention is a long-term goal, but – like most public health research – a focus on the cure usually comes first.

“If we look at other areas of health like cardiovascular disease, the first wave of progress was in having effective treatments. The next wave was working out how you can prevent people becoming unwell through changing diets, increasing exercise and stopping smoking,” he says.

“We now have good treatments for mental health, so one of the next frontiers is prevention – and there’s early signs we can do that at scale.”

And while an increased attention on mental health in light of COVID-19 is welcome, there now needs to be action, he says. “I think the next year or so will really determine whether improved mental health and wellbeing is a lasting legacy of what’s happened as a result of COVID or whether it’s just another false dawn.”

 

Technology Update: Telehealth

Article from: Counselling Australia Journal: Volume 23: Number 2 – Winter 2022 

Telehealth has been thrust into the mainstream since the COVID-19 pandemic limited physical access for many essential healthcare services. This created much-needed change in telehealth services – now with more people, from any location, having timely access to a broader number of healthcare services.

Bespoke telehealth software Coviu is one of the most widely used telehealth solutions in Australia, with over 90,000 practitioners using the software – but there are many other options for health providers. General video platforms like Teams and Zoom offer reliable and easy-to-use video solutions, and bespoke telehealth solutions such as Cliniko are tailored to suit health professionals.

We asked Coviu, the platform that has conducted over seven million consultations, to share tips for choosing a telehealth video platform.

Questions to ask when choosing a telehealth video platform:

  1. What function do I need this for now and in the future? Thinking about your goals in each subsequent step is important.
  2. Can I afford it now and into the future? What pricing options are provided?
  3. Can I try before I commit? Does the platform offer free trials?
  4. Does it meet Australian relevant laws and legislations? Check privacy and information security requirements at the Office of the Australian Information Commissioner.
  5. Where is the data stored?
  6. Does it have the features and tools you need to conduct consultations?
  7. Does it work on the devices you use?
  8. Is the system regularly enhanced?
  9. Is there adequate support? Are users kept well informed about changes or issues?
  10. What is the uptime and availability like of the system? How fast is the system to use?
  11. What is the usability like? Is it easy to use without training?

Information for health providers about telehealth

Telehealth guidance for allied health professionals – Allied Health Professions Australia

Checklist for telehealth services – Australian Government

Telehealth – Australian Digital Health Agency

Note-taking: the ins and outs

Article from: Counselling Australia Journal: Volume 23: Number 1 – Autumn 2022 

It is extremely important that professional supervisors have a good knowledge of what is appropriate and what is not with regard to note-taking. Not only do professional supervisors need to be aware of their own notes, but they also need to ensure their supervisees are keeping appropriate notes. Notes can be subpoenaed and, therefore, if they are not correctly written, the conduct of the supervisee and their professional supervisor will be brought into contention. Notes need to be legible, concise and accurate (Despenser, 2004; Presser & Pfrost, 1985).

For the supervisee, accurate notes are useful when debriefing with your professional supervisor, particularly if a difficult case was experienced several weeks before your professional supervision. Reading your notes the day after seeing a client can also be enlightening – you may find you have been judgmental, or your own belief system is interfering with your objectivity. Read notes critically, but do not change them; learn from them (Despenser, 2004; Presser & Pfost, 1985).

Taking notes is a contentious issue. Should you take notes, and if so, how much should you document and how should you reflect statements? What words are appropriate and what words will leave us professionally vulnerable? There is no real answer; but consider: will your notes be adequate and not incriminating if you are called upon by a court to divulge them, and will your client sue you after reading them? It is a good idea for professional supervisors to critique their supervisees’ notes, particularly those of new supervisees.

Clarity in documentation

The following is an excerpt taken from the American Counseling Association and written by Robert W Mitchell, ACSW. This document, entitled Documentation in Counseling Records, is relevant for any professional who is required to take notes (Mitchell, 2000; see also Armstrong, 2006).

Mark Twain once said to would-be writers, “As to the adjective, leave it out.” His words have meaning to us today. He meant that when you write an adjective, for better or for worse, you give an opinion. Adjectives must be carefully chosen, or even replaced, if language is to be clear and precise.

Examples of the need for clarity and precision are the focus of this article. Your written words are the only record of a session you have with a client, and those will count for nothing, for your agency’s purposes or in a courtroom, if you have not written them down accurately.

Let’s take an example: The sky is blue … no, the sky is generally blue … no, the sky generally appears to be blue… no, in some parts of the world, what is generally thought of as the sky sometimes appears to be blue. We sometimes make things harder on ourselves when we go to extremes. All we need to say is the sky is blue. In many instances, the work we do is simple and very straightforward; we don’t need to mystify it with complicated or confusing words.

Here’s another example: Jerry is exhibiting signs of depression … Jerry is depressed. These sentences are grammatically correct, yet I am unsure what exactly is meant. An attorney would have a great time with either of those statements, saying the writer was judgmental, prejudiced. The client was simply a quiet, unassuming person whose behaviour produced unwarranted and false conclusions. To eliminate that possibility, all you need to do is add a simple clarifying phrase. If Jerry is depressed or showing depression, add something like ‘because he lost his job’. If Jerry is repressing his emotions, add ‘by not answering questions and by changing the subject’. What clues tell you Jerry is depressed? Add ‘he said he has not been able to eat or sleep and is concerned about the crying spells’. Now your conclusions are supported with specifics.

Let’s consider more examples:

  • A favourite but inadequate phrase in records involves ‘negative attitude’. Again, that is too vague and too judgmental. To make it clear, write something like: ‘learn to discuss problems instead of throwing things’.
  • A frequent goal is ‘improve hygiene’. That’s too vague because it doesn’t tell you enough of a story. You must be specific. How about: ‘brush teeth and shower each day’?
  • Don’t write: ‘learn to become more independent’. What does that mean? Set up a business? Leave a husband? The specific goal could be: ‘get up in the morning and report to job on time’.
  • ‘Increase self-esteem’ is another favourite goal, but it’s difficult to really sink one’s teeth into such a phrase. How about: ‘will not be critical of self or personal decisions about disciplining children’. See the difference?
  • The record may read: ‘client participated in chalk talk’. What does ‘participated’ mean? Will every reader understand that a ‘chalk talk’ in this instance is a chemical dependency lecture? Did the client talk? Cry? Take a swing at another client? Or at you? Someone can participate in an active or a passive way. So one word doesn’t tell much. To clarify ‘participate’, add for example, ‘client revealed examples of how he had fooled himself about the increasing use of drugs. He reported denying the importance of wife’s complaints. The group encouraged his willingness to open up.’
  • Since part of our topic concerns communication, let’s take the phrase ‘communication problem’. Again, what does this mean? Why not list the exact problem; for example, ‘stuttering’, ‘speaking too fast’ or ‘talking around the subject’.
  • Is your client withdrawn? How do you know that? Write instead, ‘Suzanne is withdrawn as evidenced by the fact that she spends all her time in her room and refuses to even eat meals with her family.’
  • To characterise someone as ‘aggressive’ is not enough. Does the client fight? Push? Scream? Kick? Do not leave room for interpretation. If the client described eventually takes you to court, the term ‘aggressive’ used alone could be interpreted by the attorney as a positive characteristic, not a negative one.
  • If a client is unemployed, there may be more to the situation. Clarify your entry by adding something like ‘has been fired from last three jobs for drinking and excessive absences’.
  • You can define the term ‘nervous’ by writing something like ‘not eating; sleep is not restful; screams at children’.
  • Instead of ‘feels bad’, write ‘history of high blood pressure and heart condition’. Remember: one can feel bad physically and/or emotionally. That holds true for another one-word problem: health. Enter something like ‘asthmatic condition requires expensive medication, so the client does without’.
  • When the client is ambivalent, you need to know why. So does a record user. Enter something like ‘She cannot make a decision about continuing in a marriage with an abusive spouse’.
  • We often think we are describing a behaviour when we say, ‘Henry is lazy’, or ‘Laura is aggressive’, or ‘Karen is withdrawn’. These statements do not describe behaviours; they make undefined judgmental observations. That could be disastrous for a supervisee and the agency. What characteristics or symptoms give you cause to think the way you do? Write them down!

As you are choosing words, remember, it is a complex task. Your choice could convey, deliberately or not, a view that tends to be too negative. Consider these examples and decide which is better: dumb or limited intelligence; cheap or economical. It is vital that your words be clear and precise to satisfy your profession, external auditors, your client and attorneys, should the need arise. It is necessary to substantiate your observations and give them authority. Remember: good entries are precise and current.

There is also the matter of timeliness. The word ‘current’ is a directive to record information immediately. Waiting even one day can blur accuracy. Those who wait until the last minute to write their entries often suffer from fainting spells, anxiety attacks and acute writer’s elbow – a heavy price to pay.

Your client should be an active participant in setting goals, writing staff notes and plans and document client participation, perhaps including the client signature. Set goals the client will understand, agree with and accept. Objectives must be specific, measurable and meaningful to the client. Set a date for achievement of those goals. Define the methodology to be used in goal achievement. Do not create a reasonable doubt – that’s a lawyer’s job! Using words that are not specific or that create vague impressions could equate to an opinion, leaving room for reasonable doubt and the possible destruction of your credibility.

The writer’s reasonableness and credibility can be assumed not only from the words but also from the readability and appearance of the record. Did you ever stop to think that a record’s appearance affects a reader just as the appearance of a speaker affects a listener? There are several major factors that will influence the written word’s credibility and clarity:

  • Scrawled, scratchy or sloppy handwriting, which is difficult or impossible to read, may make the writer appear irresponsible, fairly or unfairly.
  • Small writing that is crammed into a small space not only says something about the writer’s concept of what is important but also frustrates the reader, who may already be looking for a way to use the record against you.
  • Disorganised filing, half-completed forms and a rambling assortment of ideas leave too much room for doubt.

Not taking care of the appearance of a document may be construed as an indication of disregard for the client and a lapse in professional accountability.

Excerpted from: ACA Legal Series: Volume 2: Documentation in Counselling Records Author: Robert W Mitchell, ACSW Series Editor: Theodore P Remley, Jr, JD, PhD

Reprinted kindly with permission for educational purposes, in gratitude to the authors and American Counselling Association.

For more information, see www.counseling.org/Publications/FrontMatter/72851-FM.pdf.