Consultation and Advocacy: An Integrated Approach for Aging Care Management

Consultation and Advocacy: An Integrated Approach for Aging Care Management

Survey of Research in Human Development for Professional Counselors

Abstract

            This paper presents a discussion supporting the integration of both Consultation and Advocacy approaches to counseling in service delivery paradigms for members of the aging population. A hypothetical Care Management case is used to show how the two distinct approaches are complimentary, and how using an integrative approach is empowering to the individual, and contains within it the potential for maximizing their wellbeing.

  

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            Consulting and Social Justice Advocacy are two distinct, yet crucial aspects of the Mental Health profession, each vying for recognition as a significant component of its gestalt.  In its totality, the profession purports to function primarily as a service provider with the goal of mitigating the resolution of difficulties encountered in the lives of individuals, organizations and other systems. Yet how these two distinct facets, consultation and advocacy, go about the business of completing their work is a subject of continuous scrutiny by researchers in the field of mental health counseling. Perusing the literature in both domains, one easily recognizes that discussions about them speak more about their distinctions than their similarities, further reinforcing their dispersion. The dilemma facing these strange bedfellows is not easily apparent and perhaps therein lays a challenge for mental health counseling researchers.  Ongoing discourse highlighting the qualities unique to each brand of service delivery may assist in furthering a deeper understanding of them as more alike than dissimilar, thus articulating more succinctly their role and function within the context of professional practices, as complimentary rather than disparate.

            Kurpius and Fuqua (1993) wrote that the term consultation includes a wide range of services that can vary substantially (p. 599), and drawing from Lippitt and Lippitt (1978), they list a variety of “consultant modes of intervention” which typify the range of consulting services ascribed to providers of mental health services. Their list describes the decidedly passive role of the consultant as “expert”, “problem solver”, “linker”, “process counselor”, “trainer”, and “objective observer”. In their article ‘Fundamental Issues in Defining Consultation’, the writers also quote from a number of other sources that have identified commonly perceived modes of interventive practices. These include Schein (1969, 1978, 1991) who uses the terms “purchase of expertise”,  “doctor-patient”, and “process consultant”, and Caplan & Caplan (1993) who characterize the consultant as a “mental health expert”, “client centered case consultant”, “consultee centered case consultant”, “program centered administrative consultant”, and “consultee centered administrative consultant”.  Moe, Perera-Ditz, Sepulveda, (2010) present a concise definition of consultation in the article titled ‘Are Consultation and Social Justice Advocacy Similar?: Exploring the Perceptions of Professional Counselors and Counseling Students’. In this article (referencing Brown, Pryzwansky, & Schulte, 2010, Kampwirth, 2006, Kurpius & Fulqua, 1993), the authors identify consultation as an activity that “typically involves acting on behalf of an identified client through interaction with another professional consultee or other stakeholder in the client’s welfare”.  

            These descriptions serve to characterize the consultant/client relationship as being predominantly vertical in hierarchical structure, and evidentiate how power in this relationship is transmitted in a top-down fashion. The client, possessing a lesser degree of knowledge about a critical situation, reaches out for assistance from the consultant, who is better equipped with the skills set required to adequately address the problem. When encountering their personal limitations, the consultant does likewise, and turns to assistance from one possessing an even greater degree of perspective in order to ameliorate the problem. The consulting relationship is summarized in two outstanding features: (a) the client actively seeks out the assistance, and (b) the client is given theoretically based advice regarding how to address the problem (largely ignoring the context in which they occur). In other words, within the consulting model, the client comes to the counselor, problems in tow, mainly seeking guidance and internal relief from the pressures and difficulties of a particular situation.

             Perhaps Ivey & Collins see definite limitations in this style of counseling. In their article ‘Social Justice: a Long Term Challenge’ (2003), they address the point that it is virtually impossible to solve some individual problems if the context in which they occur does not change. Moe et al., (2010), referencing Prilletensky & Prilletensky, (2003), and Constantine, et al., (2007), state that those using the social justice framework are more prone to synthesizing concepts from the social justice paradigm with those of other key counseling perspectives such as multicultural theory (p. 107). Multicultural theory as defined by Ivey & Collins (2003) is “an integrated theory contextualizing the field” (p. 293). The authors compare traditional counseling approaches with those of the multicultural approach, describing the traditional methods as focused primarily on the discovery of the role of the past in the present, with application of  behavior change treatments to facilitate adaptation to changing conditions.

            Multicultural theory, on the other hand, places greater emphasis on “the importance of expanding personal, family, group and organizational consciousness of the place of self–in-relation, family-in-relation, and organization-in-relation” (p. 293), supporting the need for counselors to incorporate the use of systems approach with the consulting approach for identifying barriers that restrain the client from reaching their full potential. With respect to the aging population, social justice theory would suggest that any oppressive system that treats minority populations as second class (i.e., less deserving of equal access to resources) is considered a barrier. Incorporation of the multicultural perspective in counseling practice with aging populations equalizes the power differential, and reduces the impact of such discriminatory practices that endow certain individuals with privilege, and rule others out as unworthy. Integration of the consultation approach and the advocacy approach promotes best practices by providing a solution that both relieves personal problems and resolves the contextual barriers facing the client.

            The integrated approach is emerging as the preeminent approach for service delivery, and in my role as a geriatric care manager this approach is quite useful as the premiere method of helping. This “shift in the counseling paradigm” (Ratts, 2008) is most evident in the manner in which “clients” are identified. For instance, in our work as service providers we are encouraged to use terminology that is solution-focused and strength-based, and so we refer to our “clients” as “Participants”. Using this terminology reframes the nature of the relationship, and characterizes the client less as an individual who is a recipient of services, and more so as one who is an equal contributor in the helping process. Participants meet the consultant in the middle, according to their strengths and present level of ability. When a resource is needed as a channel for meeting service demands, instead of the consultant calling the resource on behalf of the Participant, the Participant instead is given the contact information and encouraged to do the footwork. If an application for housing services needs filled out, the consultant offers their assistance in filling it out, but the Participant is encouraged to rely primarily on their own ability, and the help of informal supports (family, friends) to complete the task. The role of mental health training in this event is important for cultivating self-reliance in the individual where lacking, thus empowering them to advocate on their on behalf.  Collaborative empowerment in service delivery helps individuals remain active in their communities, rather than warehousing them out to nursing homes and long-term living facilities.

            The theory behind this approach has been discussed at great length in the article titled: A Framework for Understanding the Consultation Process: Stage by Stage (Buysse & Wesley, 2004), wherein the authors identify consultation as an eight stage process. An integrated lens may be used to support its significance as a valid approach to service delivery in the field of geriatric care management.

Stage	Consultation lens	Social Justice lens	Integrated lens
1. Gaining Entry	Individual is the problem, strives to change the individual in the situation	Individual has a problem, strives to change the situation	Problems are inside and outside the individual
2. Forming relationship	Establish parameters of relationship, ground rules for participation	Frame relationship as both a process and a goal (Adams, Bell & Griffin, 2007. Pg. 3)	Combine both approaches and moves against the status quo (Adams, Bell & Griffin, 2007. Pg 3)
3. Gathering Information	Identify individuals’ contribution to problem	Identify external stifling factors contributing to the problem (activist mentality)	Explore and identify internal and external contributing factors as barriers to problem resolution
4. Setting the Goal	Consultant writes goals for the client	Advocate creates strategies for client to use	Designs strategies with the client, based on their unique abilities, strengths and capacities
5. Selecting a Strategy	Consultant advises client on “what to do”	Advocate identifies environmental issues for the client	Counselor discusses options with client and encourages them to chose the problem they’d first like to address
6. Implementing the Plan	Consultant remains objective, and available for further advice	Advocate works closely with client, providing “hand-on” assistance as active change agent	Counselor maintains appropriate distance, Supports and encourages client (with informal supports) to be the change agent
7. Evaluating the Plan	Monitors progress in planned follow-up sessions, discusses issues in retrospect	Assists client in understanding the context of the oppressive environment, and empowers them with self-advocacy skills, so they may become more self-sufficient (Ratts, 2008)	Continually monitors the progress, and reassess the plan as needed; cultivates the ability to be flexible (Ratts, 2008. Pg. 6)
8. Holding a Summary Conference	Summarizes the outcomes and identifies successes and failures	Prepares client to effectively manage similar problems in the future (Brack, Jones, Smith, White & Brack, 1993. Pg. 620)	Paves the way for on-going collaborative interventions. Plans series of follow-up meetings to monitor progress

            The following example shows how an integrated approach would best meet the needs of an aging client participating in a service delivery paradigm that serves individuals by helping them to remain independent in their homes, as opposed to being warehoused in short or long term nursing facilities.  In this example, the consultant would be the Care Manager, and the client would be known as the Participant.

Participant Profile

            John D. is a recent referral to the County Area Agency on Aging. Referral was made by the Social Worker at the local General Hospital. This Participant is a 78 year old male who lives alone in remote home location with no informal supports. The Participant ambulates with a cane. He has been diagnosed with Depression, Hypertension, Glaucoma and GERD, and takes physician prescribed medication treatments including Wellbutrin, Amlodepine, and Prilosec. He had recently been admitted after sustaining a head injury due to a fall that occurred while transferring from the shower. The Participant reported that the fall was due to sudden onset of dizziness. The Participant sustained a concussion, took public transit to the hospital and was admitted, remaining under observation for three days, and was discharged to his home. He has no permanent impacts as a result of the injury, however, the Participant did exhibit signs of bladder incontinence. He is alert and oriented to person, place and time. The Participant seemed under normal weight for his height and frame. His monthly income amount totals approximately $927 Social Security, and a pension of $343. His hospitalization insurance is through Advantra. Care Management services recommended for this Participant are as follows: PERS (Life Alert), Adult Briefs, Senior Companion Program, Interfaith Volunteer Caregiver Program, and Safety for Seniors Program. It is also recommended the Participant begin Meals on Wheels Services.

Consultation Process

Stage 1.  Gaining Entry: A telephone call to the Participant is made to schedule the meeting for the initial Level of Care Assessment, and the Care Management Instrument assessment.

Stage 2. Forming relationship: Care Manager begins to build rapport and trust in the onset of the relationship with the initial phone call. Counselor identifies the Particpant’s unique characteristics, strengths, risks and resiliencies, and begins to consider how these will factor into intervention strategies later in the process.

Stage 3. Gathering Information: Care Manager asks closed ended questions when harvesting for specific information. Open-ended questions are used to help facilitate the Participant’s elaboration on the details of an inquiry. For instance, the Care Manager may ask the Participant to describe a typical day in his life, or to outline the patterns of the week, in order to gain a perspective of the individual range of activity, and to discern in depth his level of independence with activities of daily living. 

Stage 4. Setting the Goal: During the assessment, the Counselor identifies risk and protective factors in the Participant’s life. Formal and Informal supports are identified, and the counselor engages these as resources that would be of use to the Participant when designing interventive strategies for meeting his service needs.

Stage 5. Selecting a Strategy: Participant identifies his main desire as being a wish to remain in his own home. Counselor selects appropriate resources and collaborates with the Participant in enlisting their assistance for meeting that goal. To address the Participant’s incontinence needs, the counselor presents three separate options for service providers, describes the pros and cons in their particular range of services, and gives Participant choice to identify and select his preferred provider. To address depression, Counselor arranges with the Senior Companion Program to match a volunteer friendly visitor according to the Participant’s preferences (male, female, time of day for visit, day of week etc.). The Participant is given the volunteer’s contact info, and is encouraged to make the outreach contact himself. Likewise, using the Interfaith Volunteer Caregiver Program, a local volunteer would be linked with the Participant by providing transportation to the grocery store. The Counselor would also help the Participant enroll in the local ACCESS elder transportation system, which the Participant would use for trips to doctor’s appointments. To meet the Participant’s social needs, the counselor would identify the local area Senior Center, and encourage the Participant to participate in its program offerings. Coordinating these services on behalf of, as well as in tandem with the Participant, will help to reduce the barriers that keep him isolated from the community, and enable him to more fully engage his spectrum of capacities, simultaneously promoting an improved quality of life.

Stage 6. Implementing the Plan: The Counselor and the Participant make the contacts with service providers and organizations and activate the solutions.

Stage 7. Evaluating the Plan: Monitoring occurs through telephone calls at the two-week point, and then monthly thereafter.

Stage 8. Holding a Summary Conference: A home visit is scheduled at the six-month point, and then a complete reassessment is completed annually.

Summary

            When faced with a critical situation, clients require the assistance of someone who understands how the system can stand to interfere with those needs being met. Service delivery systems are quite complex, and individuals often require the skills of an informed expert to address and help resolve their problems. This is why it is of the utmost importance that the counselor of today be equipped with the education, skills and abilities to deal with the issues that are endemic to the individual, as well as those that are specific to the institutional systems they must interact with, in order to have their service needs met effectively, thereby ensuring continuation of their highest level of function.

References

Bindman, A. J. (1959). Mental health consultation: Theory and practice. Journal of Consulting     Psychology, 23(6), 473-482. doi: 10.1037/h0046255

Brack, G., Jones, E. S., Smith, R. M., White, J., & Brack, C. J. (1993). A primer on consultation theory: Building a flexible worldview. Journal of Counseling & Development, 71(6),    619-628.

Buyusse, V. & Wesley, P (2004). A Framework for understanding the consultation process:         Stage-by-stage. Young Exceptional Children January 2004 vol. 7 no. 2 2-9

Dickinson, D. J., & Bradshaw, S. P. (1992). Multiplying effectiveness: Combining consultation    with counseling. School Counselor, 40(2), 118.

Kurpius, D. J., & Fuqua, D. R. (1993). Fundamental issues in defining consultation. Journal of     Counseling and Development : JCD, 71(6), 598.

Moe, Jeffry, Perera, Dilani & Sepulveda, Victoria (2010). Are consultation and social justice         advocacy similar? Exploring the perceptions of counselors and counseling students.         Journal of Social Action in Counseling & Psychology, 3, 106-123

Nash, R. J. (2010). “What is the best way to be a social justice advocate?”: Communication          strategies for effective social justice advocacy. About Campus, 15(2), 11-19. doi:     10.1002/abc.20017

Ratts, M. J. (2008). A pragmatic view of social justice advocacy: Infusing microlevel social           justice advocacy strategies into counseling practices. Counseling and Human           Development, 41(1), 1-8.

Shim, E. (2008). Pastoral counseling of older adults: Toward a short-term integrative approach.    Pastoral Psychology, 56(3), 355-370

In this discussion post we are asked to identify a challenge and a hope from Tang's article, and describe how it resonates personally.

The challenge that I find personally relevant is that which charges those exercising the role of vocational counselor to develop practice standards that satisfy professional expectations with regard to the area of diversity. Tang (2003) identifies one of the major issues facing emerging vocational counseling professionals as being a “lack of ecological consideration” (pg. 63) when applying its theoretical methods. This means they tend to neglect what social work has identified as the person-in-environment (PIE) perspective, which recognizes “contextual factors’ influence” on a person’s career development. Elements such as socio-economic background, gender, education, and even genetic propensity, combine as relevant factors in determining the individual’s ability to adapt to the demands of an ever-changing environment. Tang opines that integration of contextual factors into career intervention strategy has yet to be developed.

The hope identified is related to the idea that no matter how daunting the task, counseling professionals seem to possess both an innate fortitude and an unwavering capacity for adjusting to stumbling blocks that threaten to impede their work as they strive to advocate for change on behalf of individuals and communities. Tang (2003) states on one hand, “the lack of cohesiveness between practitioners and researchers presents a problem for the validity of both theory and practice” in vocational development, yet on the other hand, he celebrates its capacity for “impressive growth in its ability to advance theoretical concepts” (pg. 63), in spite of the disconnect between theory and practice.

Change is fundamental (Kelly, 1999), and as far as such is the case, mental health counselors are charged to face the challenges of adapting to the constant flux and flow of changes within the environment. In the article Postmodernism, constructivism, and multiculturalism: three forces reshaping and expanding our thoughts about counseling (2000, pg 5), author D’Andrea states “ethnocentric constructions of mental health and illness continue to dominate the counseling profession”. With regard to the relevance of the challenges and hopes to my own specific area of focus, it appears incumbent upon me as a general mental health counselor to develop strategies for connecting theory to practice by designing interventions that are culturally specific, yet pertinent to the needs of a variety of emerging population clusters.

One hundred years ago, population in the United States consisted mainly of homogeneous groups of individuals who were identified as belonging to a particular ethnic or racial heritage. Mental health for them was strongly related to how well they managed identity conflicts that sprang from dilemmas placing them at odds with fidelity to the values of their group. One’s ethnic ideals superseded the larger national sense of identity, and loyalty to the ethnic group was highly prized. Members of racial and ethnic groups were discouraged from intermingling. People married within their own religious denominations and ethic subgroups, and in this manner their values were contained and advanced generationally.

One hundred years later genetic loyalty became watered down through the process of urbanization, forcing subgroups to intermingle in the schools and in the workplace. As a result people developed larger community identities and the smaller differences mattered less. This process of cultural decolonization brought people together, enabling them to intermingle in ways that produced a new cultural synthesis.

Nowadays, we tend less to identify through ethnicity and racial differences, and look to similarities in shared interests as a basis of commonality in the communities we create with others. We have become a highly diverse group of people no longer separated primarily by cultural values, but rather we construct ourselves according to values and interests of those with whom we identify, and with whom we share interests. If culture is a ‘work in progress’, a moving target, a construct less embedded in a sense of identity related to a specific cultural genesis, then it is important as a mental health counselor in training to remain vigilant to the impact of cultural diversification, and be ever mindful of its power to shape the world and the mental health counseling profession.


References

D'Andrea, M. (2000). Postmodernism, constructivism, and multiculturalism: Three forces reshaping and expanding our thoughts about counseling. Journal of Mental Health Counseling, 22(1), 1-16. Retrieved from http://search.proquest.com.library.capella.edu/docview/198699817?accountid=27965

Kelly, K. R. (1999). Coda: A contextual perspective on the future of mental health counseling. Journal of Mental Health Counseling, 21(3), 302-307. Retrieved from http://search.proquest.com.library.capella.edu/docview/198780120?accountid=27965

Tang, M. (2003). Career counseling in the future: Constructing, collaborating, advocating. The Career Development Quarterly, 52(1), 61-69. Retrieved from http://search.proquest.com.library.capella.edu/docview/219388419?accountid=27965

Career Counseling and Technology

Career Counselor and Technology

Themes of human development have long been the focus of research efforts to study patterns of adaptive change in environments, particularly within the age range involving early adolescent years. Eccles, Midgley, Wigfield. Buchanan, Reuman, Flanagan and Iver (1993), in a study titled The Impact of Stage-Environment Fit on Young Adolescents’ Experiences in Schools and in Families, identify some of the unique challenges facing this population cohort. Their inquiry explores the transitory nature of the adolescent period, and determines that the greatest risks they face are those accompanying changes at both personal and environmental/social levels (pg. 90). The changes at the personal level are those related to biological and hormonal changes at puberty, changes in cognitive development, and sexual identity formation. Changes in environmental/social level are those related to “social role definitions”.

The ‘social role definition’ aspect has become a favored topic of investigation by researchers in the field of vocational behavior. One such researcher explores career development as related to self-construction during adolescence, and writes about it through the evolving ‘theory of career construction’ lens. In their article titled Career development in the context of self-construction during adolescence (2010), authors Unsinger and Smith identify the five overarching life stages outlined by D. E. Super (1963) as being growth, exploration, establishment, maintenance, and decline. These are particularly relevant to adolescents transitioning through the secondary school education gauntlet, because ultimately these stages bear strong influence on their ‘self-in-the-larger-world’ (pg. 580). Stage theory generally informs us that in order to pass from one period of development, one must master the tasks of its precedent. This being the case, these five phases unavoidably must be traversed to completion in order to satisfy the mastery goals of subsequent phases, though not necessarily in linear fashion. A more recent model proposed by Savickas (2005), the life-space career development theory, advances Super’s theory, arguing that careers do not unfold, but rather they are constructed. The theory asserts that “vocational behavior emerges as an individual actively engages in making meaning of his or her experiences, as opposed to discovering pre-existing facts” (np).

Herein lies the challenge facing the school counseling/career counseling professional: to help individuals effectively and efficiently navigate through, negotiate, and satisfy the demands of vocational developmental tasks. For even though these are not necessarily linear, they are progressive, and thus it is incumbent upon the vocational counselor to properly identify the deficiencies within the individual in terms of those areas which have not been adequately addressed in sequence, and to work with that individual in an attempt to spackle the task accomplishment gaps, so the individual may move unencumbered toward reconciliation of challenges in subsequent phases. In doing so, they accomplish what Super (1963) further identifies as the five vocation developmental tasks: (a) crystallizing, (b) specifying, (c) implementing a vocational preference, and subsequently (d) stabilizing, and (e) consolidating in a vocation (pg. 580). For the vocational counselor working with the adolescent population in secondary educational settings, the challenge to help them rise to meet these benchmarks may seem daunting, but the professional who is passionate about the work, may find the prospective rewards inherent in the challenge energizing and inspiring.

Examples modeling innovative use of vocational creativity abound and are apparent in two articles “Texting paid off” (Meinhardt, 2011) and “High tech = High touch” (Turner, 2009). These two articles describe the manner in which technology may influence results. The solutions envisioned in these two examples, one a high school principal who enlisted the services of a social media design strategist, and one a high school counselor, display the effective use of innovative technology. Both identify its potential for satisfying the five developmental tasks identified by Super (1963), pointing out in summary how cell phones and other forms of technology and social media can be an “effective tool to help students stay engaged with the school and the true mission …. education” (Super, D. E., 1963). For example, using cell phones to connect groups with text prompting motivates them to be on time for class, helps them to be ‘at the ready’ for entry into the ‘ante realm’ of vocational development, where, primed for entry through its portal, they are thus better disposed to meet developmental challenges.

Web Based Pilot Study Proposal

A possible web-based platform environment utilizing interactive activities that support theory-based practices proposed by Super and Savickas is indicated in the following suggested pilot study proposal. The proposal involves a Web based virtual campus design strategy linking educational and vocational goals. The featured cohort includes two groups. The first group is an experimental group containing select adolescents 14 years of age who have not completed ninth grade who are incarcerated in residential group home housing. The second group, a control group, features individuals of the same age and grade level, who are honors students, and who have not completed ninth grade level. The curriculum would span a period of one year, following a quarterly schedule. Students would be equipped with wireless capacitated 4G cell phones (equipped with hotspots), and personal computers. Coursework would be monitored by instructors and completed from home during the hours of 10am through 4pm each day, Monday through Friday. Students would learn from each other by collaborating and interacting through chat room discussion, completion of discussion board posting. The honors level students would be excused from participation in regular classes, however, they would check in daily with their homeroom class so as to remain socially supported within the context of normative peer environments. This is strictly the germ of an idea, which more fully extrapolated would extend far beyond the range of this discussion board posting.

References

Eccles, J. S., Midgley, C., Wigfield, A., Buchanan, C. M., Reuman, D., Flanagan, C., & Mac Iver, D. (1993). Development during adolescence: The impact of stage-environment fit on young adolescents' experiences in schools and in families. American Psychologist, 48(2), 90-101. doi: 10.1037/0003-066X.48.2.90

Meinhardt, K. (2010) Texting paid off. Retrieved March 15, 2013 from http://edsome.com/2010/06/texting-paid-off/

Paisley, P. O., & Borders, L. D. (1995). School counseling: An evolving specialty. Journal of Counseling and Development : JCD, 74(2), 150. Retrieved from http://search.proquest.com.library.capella.edu/docview/219008799?accountid=27965

Pope, M. (2000). A brief history of career counseling in the united states. The Career Development Quarterly, 48(3), 194-211. Retrieved from http://search.proquest.com.library.capella.edu/docview/219386837?accountid=27965

Savickas, M. L. (2005). The theory and practice of career construction. In S.D. Brown, R.W. Lent (Eds.), Career development and counseling: Putting theory and research to work, Hoboken, NJ, Wiley & Sons (2005), pp. 42–70

Super, D. E. (1963) Vocational development in adolescence and early adulthood: Tasks and behaviors. In D.E. Super (Ed.), Career development: Self-concept theory, College Entrance Board, New York (1963), pp. 17–32

Smith, H. B., & Robinson, G. P. (1995). Mental health counseling: Past, present, and future. Journal of Counseling & Development, 74(2), 158-162. Retrieved from http://ezproxy.library.capella.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=9512046698&site=ehost-live&scope=site

Tang, M. (2003). Career counseling in the future: Constructing, collaborating, advocating. The Career Development Quarterly, 52(1), 61-69. Retrieved from http://search.proquest.com.library.capella.edu/docview/219388419?accountid=27965

Turner, T. (2009) High tech = high touch. Retrieved March 15, 2013 from http://www.ascaschoolcounselor.org/article_content.asp?article=1105

Usinger, J., & Smith, M. (2010). Career development in the context of self-construction during adolescence. Journal of Vocational Behavior, 76(3), 580-591. doi: 10.1016/j.jvb.2010.01.010

History of the Counseling Profession

History of Counseling

While it would be conjecture to state which events in the history of the counseling profession had the greatest impact on its development, two major events within the timeline stand out for this learner as milestones in the development of the counseling profession. These are the Mental Health Reforms of the early 20th Century, and the Community Mental Health Centers Act. These two developments are important because of their contributions to the shaping of the profession’s philosophical values, which include wellness, resiliency, empowerment, advocacy, development and prevention. (Healy & Hayes, 2011)

The relevance of the Mental Health Reforms owes to the efforts of Clifford Beers's A Mind That Found Itself (1908), written from the author’s personal experience on the deplorable conditions in mental health institutions. It is regarded by many in the profession as a seminal work on prevention in the United States (Bloom, 1984; Long, 1989). Clifford Beers was a Yale student who had been hospitalized several times throughout his life for mental illness, and as a result of his experience, he advocated for better mental health facilities and reform in the treatment of the mentally ill. His work is largely considered to be “the impetus for the mental health movement in the United States”, one of the major milestones in the development of the counseling profession (Gladding, 1996).

The Mental Health Study Act was enacted by the U.S. Congress in 1955, leading to a 5-year study of the human and economic problems of mental illness. It concluded with the Joint Commission on Mental Illness and Health Report of 1960. The Commission ultimately recommended that despite the importance of prevention, emphasis was needed on early, community-based treatment (Keist & White, 1997, p. 3).

These events in the timeline helped turn the tide in human social services from the traditional application of the medical model perspective, which is clinically focused on the individual as source of the problem, to a focus on education, solution-focused and preventative methods for dealing with mental health issues.

The following professional associations were explored in depth:

The National Board for Certified Counselors (NBCC®), is an independent not-for-profit credentialing body incorporated in 1982 to establish and monitor a national certification system, to identify those counselors who have voluntarily sought and obtained certification, and to maintain a register of those counselors. Currently, its membership includes over 36,000 certified counselors. (from the website: http://www.nbcc.org/)

The American Counseling Association (ACA) founded in 1952, is a not-for-profit, professional and educational organization that is dedicated to the growth and enhancement of the counseling profession. It is the world's largest association exclusively representing professional counselors in various practice settings. (from the website: http://www.counseling.org )

International Association of Counseling Services (IACS) encourages and aids counseling services throughout the United States and internationally in meeting high professional standards, by improving its visibility and quality of services. It informs the public about competence and reliability, and fosters communication among counseling services operating in a variety of settings. Accreditation is open to University and College Counseling Centers and Public and Private Counseling Agencies. (from the website: http://iacsinc.org )

The Association for Specialists in Group Work (ASGW), a division of the ACA, was founded to promote quality in group work training, practice, and research both nationally and internationally. (from the website: http://www.asgw.org )

Association for Death Education and Counseling (ADEC) is one of the oldest interdisciplinary organizations in the field of dying, death and bereavement. Its nearly 2000 members consist of an array of mental and medical health personnel, educators, clergy, funeral directors, and volunteers. ADEC offers numerous educational opportunities through annual conference, courses and workshops, its certification program, and via its journal, The Forum. (from the website: http://www.adec.org )

Analysis of the historical and philosophical relevance of one specialized area to the practice of counseling:

American Mental Health Counseling Association

AMHCA is a growing community of nearly 7,000 clinical mental health counselors, making a critical impact on the lives of Americans and give a voice to our profession nationwide. It has served the professional needs of mental health counselors for more than 30 years. It assists its membership in career development, and assists providers in the field by working toward recognition for mental health counselors under Medicare, and in general, advocates for greater acceptance of mental health counselors currently recognized by other federal programs and private health care insurance plans. It expands professional knowledge and builds networks among professional peers for the ultimate purpose of improving service to clients. (from the website: http://www.amhca.org)

References

Feldmen, S. (2003) Reflections on the 40th anniversary of the US Community Mental Health Centers Act. Australian and New Zealand Journal of Psychiatry; 37:662-667

Gladding, S. T. (1996) Counseling: A comprehensive profession (3rd edition). Macmillan Pub Co.

Healey, A. C., & Hays, D. G. (2011). Defining counseling professional identity from a gendered perspective: Role conflict and development. Professional Issues in Counseling Journal, Spring. Retrieved on March 11, 2013 from http://www.shsu.edu/~piic/DefiningCounselingProfessionalIdentityfromaGenderedPerspective.htm

Kleist, D. M., & White, L. J. (1997). The values of counseling: A disparity between a philosophy of prevention in counseling and counselor practice and training. 41(2), 128

Working as Part of a Multidisciplinary Team

One of the major tasks of the mental health profession stated in the American Counseling Association (ACA) Code of Ethics (2005) is to “encourage client growth and development in ways that foster the interest and welfare of clients”. Professional researchers in the field of counseling strive to illuminate the meaning of this competency for mental health professionals aspiring to practice effective standards of care. Three of the best practice strategies that help counseling professionals meet these standards are consultation, advocacy, and collaboration.

Consultation for professional counselors involves “acting on behalf of an identified client through interaction with another professional consultee or other stakeholder in the client’s welfare” (Brown, Pryzwansky, & Schulte, 2010). Advocacy is a values-driven effort that strives to promote systemic change at the macro level in an effort to promote social justice where barriers to equity and access appear, and restrict full and active participation at the socio-cultural level (Crethar, Torres, Rivera, & Nash, 2008). Collaboration in counseling means working together with professionals of related disciplines, to meet the standards recommended by the ACA (Moe, Perera-Diltz & Sepulveda, 2010). Collaboration occurs at the individual level, and includes service provision by medical physicians, psychiatrists, social workers, addictions counselors, marriage and family counselors, career counselors, school counselors, and mental health counselors, to name several. Effective collaboration also occurs at the systemic level, as identified by Bryan (2009) who proposes that counselors engage strategic family-community partnerships “to enhance direct counseling services to clients”.

Mental health services are delivered proficiently and integrally when consultation and advocacy spring from collaborative efforts between professionals. The professionals, charged with exercising collaborative roles maximize the impact on the client’s well-being while engaging strategies from both internal and external sources. Internal impacts are those that affect the client directly through practical application of knowledge (theories) and skills, such as services provided by mental health counselors and addictions counselors. External impacts are maximized when staff exercises specific roles that advocate for systemic change, such as services provided by social workers (Mellin, Hunt & Nichols, 2011). When these roles collaborate to work on behalf of the client’s interest, their personal growth and development is fostered, their welfare is advanced, and the standards of ethical care are met.

An example of strategic collaboration enhancing the client’s welfare may be recognized in the following case example:

Paul, a 32-year old man, seeks counseling at a community mental health center. He has recently returned from his third deployment to a combat zone. He reports drinking frequently and feeling anxious. For the past three weeks, Paul has been extremely worried that his neighbors are spying on him. Paul's wife has tried to reassure him that he is imagining things, but he cannot get these concerns out of his mind. Paul feels reluctant to leave the house and has missed over a week of work.

The collaborative team engaging this client in this hypothetic facility includes those who exercise roles as mental health counselor, addictions counselor, and social worker. According to Brown et al (2010), these would qualify as professionally appropriate consultees by virtue of their education, training, and credentials. The social worker would help Paul connect to resources related to his status as a veteran. Such resources may include group work for those struggling with PTSD, so collaboration at this level might appear as an external link to resources at the local VA hospital. If a group does not exist, the social worker could develop a strategy for initiating one. The addictions counselor would assist Paul in recognizing his maladaptive dependence on alcohol and apply theories to assist him in coming to terms with his recovery process. The mental health counselor could possibly use appropriate mental health diagnostic tools such as the bio-psycho-social assessment and the DSM-IV-TR Statistical Manual to evaluate Axis-specific level of function, and determine appropriate referrals. The referrals (a psychiatrist/physician) may indicate psychopharmacological treatments or other higher order therapeutic interventions relevant to the symptomology displayed. In this case Paul would require in-depth assessment for agoraphobic behavior, anxiety, and paranoia (which may be related to the impact of drenching his brain with toxic alcohol, or a result of lingering effects of unrecognized/untreated PTSD, or a combination of many complex factors).

The role of each professional included on this particular multi-disciplinary team would be distinct, but their collaboration would be cohesive, and it would be comprehensive. Their strategic plan ideally would be developed according to the desires of the client, yet without compromising diagnostic altruism. Hopefully, their intentionality would culminate in integrated delivery of services, thus fulfilling the expected professional standards of care designed to meet this unique client’s service plan goals.

American Counseling Association. (2005). ACA Code of Ethics. Retrieved March 5, 2013 from http://www.counseling.org/Resources/aca-code-of-ethics.pdf

Brown, D., Pryzwansky, W., & Schulte, A. (2010). Psychological consultation and collaboration: Introduction to theory and practice. The Merill Counseling Series. (7th ed.) Prentiss Hall.

Bryan, Julia.(2009) Engaging clients, families, and communities as partners in mental health. Journal of Counseling and Development. volume 87, issue 4. pg. 507

Crethar, H., Torres-Rivera, E., & Nash, S. (2008). In search of common threads: Linking multicultural, feminist, and social justice counseling paradigms. Journal of Counseling & Development, volume 86, pages 269-278

Mellin, Elizabeth A., Hunt, Brandon, & Nichols, Lindsey M. (2011) Counselor professional identity: Findings and implications for counseling and interprofessional collaboration. Journal of Counseling and Development, volume 89, issue 2, pages 140–147.

Moe, Jeffrey L., Perera-Diltz, Dilani, & Sepulveda, Victoria. (2010). Are consultation and social justice advocacy similar? Exploring the perceptions of professional counselors and counseling students. Journal for Social Action in Counseling and Psychology, volume 2, issue 2, pages 106–123

Professional Identity and Technology

Three Topics of Equal Relevance in Mental Health Counselor Development

In the article Professional Identity Development: A Grounded Theory of Transformational Tasks of New Counselors (2010), authors Gibson, Dollarhide & Moss designed a study purporting to produce a theory of professional development. The researchers identified the process of professional counseling formation as culminating in the “successful integration of personal attributes and professional training in the context of a professional community” (pg. 23). They perceive this process to be transformational and, by their estimation, rests on three pillars:
- Embodying of the definition of Counseling
- Professional Growth
- Transformation to Systemic Identity

With respect to the first pillar, the American Counseling Association, in its Code of Ethics, defines counseling in terms of what counselors do. “Counselors encourage client growth and development in ways that foster the interest and welfare of clients, and promote formation of healthy relationships”. This statement exemplifies the essence of the first pillar. The second pillar, professional growth, promotes the focus initiated by the first, and the third pillar, transformation to systemic identity, sustains it. There is, however, a fourth pillar unmentioned in this study, and that is the pillar of ethical standards itself, which serves to oversee right relations between professionals and those they serve. These prompt and direct those guiding principles, and also shape and inform developmental progression.

With regard to the affect technology has on professional identity development in the realm of ethical practices, the proper application of ethical standards in areas such as confidentiality, privacy, informed consent, and dual relationships, present ethical challenges to counselors at each stage of development. Since it is common practice in many agencies to transmit, store and relay information over a variety of electronic means such as fax, email, voice mail, to name a few, counselors in training, beginning at internship, have access to protected information. Despite its convenience, proper use of information must be exercised if one is to maintain adherence to laws and statutes governing its transmission, no matter what mode is used.

Counselors in training who work in the mental health field (or in my case, in Geriatric Care Management) must be trained in proprietary use and practice of Health Insurance Portability and Accountability Act (HIPAA) privacy laws. If standards are to achieve their highest purpose, that being to form effective practitioners in the crucible of the ‘transformation to systemic identity’, then they must practice what is preached, and that message must generate from the heart of the formational process.

Personally, this article provokes several questions such as: Do I possess the attributes required to establish a suitable identity as a professional? How will I successfully cultivate and integrate the knowledge, skills and values that form the core essence of the profession? Will I be prepared, when the time comes, to connect theory with practice? Will the professional community confirm me as a legitimate member of its society? And, with that accomplished, will I manage to dodge potential litigious actions that, almost inevitably, will be leveled against me at some point during the course of my career? Thankfully, with insurance coverage as a safety net, the fear of losing the house, the car and the shirt are slightly detained!

On a brighter note, however, one presumes (hopes?) that the resiliencies of the profession far outweigh the risks. In our technology driven culture, we have access to a wealth of web based instructional content for continuing education and on-going formation. We use webinars, power point presentations, skype, and email, telephone, etc., to transmit learning information. Why would such use of resources not be considered worthy of use as part of a skill set when working with individual consumers of mental health services? Psycho-education, one-on-one counseling, instant messaging, video conferencing, are valid modes of service provision that have become legitimized by vanguard associations that have sprung up consequently to develop and provide policies to guide modal specific service delivery practices. (A number of such organizations are listed in the article Applying Technology to Online Counseling: Suggestions for the Beginning E-Therapist, Elleven & Allen).

The three topics, counselor formation, ethics, and the use of technology in the training and practice of counseling, are related and intertwined. If one of the major tasks of the mental health counselor is to “encourage client growth and development in ways that foster the interest and welfare of clients”, then it behooves the practitioner to adopt skills shared by the general populace in order to keep pace, and ultimately optimize choices for therapeutic service delivery (Guanipa, Nolte & Lizarraga, 2002). But perhaps more importantly, it challenges them to complete their service delivery in an ethically sound manner, that best ensures the confidentiality and security of protected health information when it is transferred, received, handled, or shared.

American Counseling Association. (2005). ACA Code of Ethics. Retrieved March 5, 2013 from http://www.counseling.org/Resources/aca-code-of-ethics.pdf

Elleven, Russell K. & Allen, Jeff. Applying technology to online counseling: Suggestions for the beginning e-therapist. Journal of Instructional Psychology, Vol. 31, No. 3.

Gibson, Donna., Dollarhide, Collette T. & Moss, Julie T. (2010) Professional identity development: A grounded theory of transformational tasks of new counselors. Counselor Education & Supervision Volume 50

Guanipa, C , Nolte, L. M,, & Lizarraga, J, (2002), Using the Internet to help diverse population: A bilingual website. Journal of Technology in Human Services, 19, 13-23.

The Story of a Boy

Geographically speaking, I have lived in several states during my lifetime. Pennsylvania, Colorado, Wisconsin and Minnesota, and Kentucky. I lived in them, and I also left them, easily moving from one to the other.


Emotionally speaking, I had also lived in several states as well, the most memorable being Shame, Anger and Resentment, though these were not so easy to leave; in fact they were, for many years, and many reasons, impossible to leave. 

However, a couple of weeks ago I made a few significant connections to some of the more elusive themes that dominated the course of my recovery over the last several years, and in doing so, found it possible to possible to bid fond farewell to these states.


I must say, these last 12 months, while the most challenging yet, apparently have been the most fruitful in the entire 35 year recovery span. 


Prior to that, I found it difficult to leave Anger and Resentment, rather, more or less, stuck in a cycle, perceiving myself as a victim of all the trauma that impacted me during the course of my life, beginning with the earliest days where I learned how to be a member within the context of a family system that spawned and molded me in preparation for entering the larger society.

I was raised by well meaning parents who had no clue about how to proceed with raising 8 children, born within 13 year span. Neither  of them came from families that offered successful models for doing so. The bleak times and impoverished circumstances under which they themselves were brought up, left them ill-equipped to meet the challenges that lay before them. However, they flew by the seat of their pants, and pretty much reacted daily as impulse dictated for dealing with the stress of the most current pressing need.


Having no skills passed on inter-generationally to help them achieve their goal and ignorant of the range of emotional and psychological needs of their offspring, they focused on what they knew, that being the needs of the body: food, shelter and clothing. The moral code of their own religious culture supplied the rule book which established acceptable guidelines for justifying their disciplinary methods. We criticize those methods today as being faulty and negligent, however, at the time, it seemed for them the only viable options; options which were justified by the cultural and moral systems which had served the disciplinary methods of the preceding generation, those that shaped and formed them.

Those methods included the use of violence as a control method for inhibiting the volition of the child, restricting its liberties to the realm of what was deemed acceptable according to a core value system that had been transmitted through their parents. The nature of this system was not such that behavioral expectations were shaped by love and encouragement, with plenty of room built in for mistakes, and learning the ropes of self-determination. No, this was a purposefully designed punitive system, where behaviors were regimented, and failures to remain loyal to its expectations were met with severe disapproval and repercussions in the form of abusive physical acts. Under such circumstances, there was no show of love, no modeling of warmth and compassion, only a climate of fear and retribution. 


But what did the child know? This was his world, and to complain or resist the governance of this system would never have entered his mind. He did what was expected and what he was told to do. His life became a matter of compliance. His daily bread and purpose became a simple task of staying out of the radar of the stressed out rulers, following orders to avoid punishment, though knowing from experience that this was not possible. All he could do was try to steer clear of becoming the next target of attack. This was the substance and form of what it meant to be 'happy'.

What did the child do with all the emotions that had not been validated within the aegis of such a regime? What happened to all the unexpressed fear, frustration, anger and resentment? The answer is that the child repressed these emotive responses. Having no safe place to in which to vent them, they got stuffed, and went underground. 


Forced to hide his true feeling and emotions and thoughts, the child began to form an alternative personality, one that would be deemed acceptable, who could live in safety under the terms of endearment established by the governors of the systemic regime. Powerless to resist, and in order to survive, thereby ensuring a secure existence without fear of violent repercussion, he adapted by developing a false self. 

 The false self did not live happily ever after. 


The false self, frustrated, defeated, stripped of its natural sense of wonder and curiosity, beat down by the constant oppression of its inquisitive nature was left feeling rather shallow and out of step with the rest of the world, and himself. Everything else all around him seemed to be full of vibrancy, eagerness, spontaneity and desire to meet the joyful challenges of living. 


But the false self living in the heart and soul of this child, could not relate; he could not just 'go with the flow', because the seed of life planted in him at his emergence into the world had been trampled, stifled and crushed. However, it had not been obliterated. Something in the self that was real, that which could not be destroyed, prevailed in spite of the obstacles inhibiting its growth.  


The child left the nest that nurtured him, that formed and shaped his values. He fled the tribe that demanded unflinching loyalty under penalty of violence, rejection and abandonment. And as he left, he took only the clothes swaddling him: Fear, compliance, avoidance. 

But wait, there's more..........

The Trip to Bountiful

Death and Dying in “The Trip to Bountiful”

 The Trip to Bountiful is a vignette in the later life of Carrie Watts, an elder southern woman living out her last chapter with her son, Ludie, and daughter-in-law, Jessie Mae, in 1940’s Houston, Texas. The story unfolds as the camera peeks in on the three inhabitants, sharing cramped quarters in their one-bedroom apartment, early in the wee hours of a summer morning. One by one, the three enter the scene, restless from the heat and the gnawing undercurrent of anxiety typifying  their shared, uneventful lives. Ludie emerges first from the couple’s bedroom (separated by curtained French doors) into the common living space which doubles as a sleeping area for “Mother Watts”), followed by Jessie Mae, seemingly reluctant to permit Ludie to savor the quiet company of his mother alone. As the dialogue ensues their relationship dynamics are slowly unveiled.

Mother Watts appears on one hand as coy and child-like, yet on the other, stubborn and determined. Ludie is hen-pecked by his pushy and domineering, pestering yet sensitive wife, whose disdain knows neither boundary nor restraint. In many ways the story of their lives is a story of their deaths, particularly with regard to the subtle ways that people die from moment to moment through small gestures of concession made in good faith to alleviate tensions constraining their most intimate alliances. Living in such close quarters puts everyone on edge, but each character in this story has their own singular unresolved crisis contributing to the blanket of doleful anxiety that knits their lives together in common.

For Jessie Mae, her dying to self is packaged in the frustration she feels for having settled for far less than she felt she deserved in marrying Ludie. She likes the finery of clothing and hair styles, and the fact of the matter is there is not enough money to support her champagne tastes. Throughout the first scene she repeatedly hassles Mother Watts about the pension check that has not arrived on schedule, blaming her for losing it, or putting it somewhere and forgetting where that might be.  Though not consciously preoccupied with physical death per se, Jessie Mae’s protestations and complaints rather indicate a desire to avoid sliding down into the dreaded toothy jowls of homelessness and insecurity: a sure fire death for an ego as fragile as hers. Ludie is a defeated man, struggling to maintain his employment status while living with the unresolved pain surrounding the death of his grandfather (which is reviewed later during the film’s climactic moment).

The main theme of the movie revolves around Mother Watts’ desire to return before she dies to the hometown and the homestead she has not seen for twenty years. Bountiful, the town where she grew up, is where she buried two babies and raised her son Ludie. She dreams of the day she could go back and “get her hands into the soil again”; to visit her old childhood friend Callie Davis, and “see Bountiful one last time” before she dies. Repeated attempts to realize her dream are foiled time and again by Jessie Mae’s persistent interference, but Mother Watts finally escapes one day unimpeded. With only a small tote bag, purse, and her prized pension check tucked secretly into her bosom, she steals off to the bus station, and on to the bus. 

During the bus ride she makes the acquaintance of a young woman, Thelma, who is dealing with her own death concerns. As it turns out, she is on her way back to stay with her parents, and await her new husband’s return from a World War II tour of duty overseas. The conversation they share during the bus trip focuses on themes of loss, faith and disappointment. The dialogue leads to a tearful fugue of reminiscence of the early days growing up as a young girl in Bountiful, and how Mother Watts laments that she could not marry the man she truly loved, and who loved her, because of class differences. Because she was a poor farm girl, while he was of the merchant class, their love could not be realized and she had to settle for an untrue love. As she recounts the situation, she cries, perhaps for the first time, to release her deep dark secret to the compassionate receptive ears of someone willing to share the burden of a lifetime of grief; someone who would understand her loss and her need to mourn, freely and finally, the death of that piece of the past that occupied her heart space for so many long years.

The town nearest Bountiful is twelve miles away, and because Bountiful is so decrepit now, it is vacant, deserted. Still, since the story is relayed over the backdrop of the Spring season, its pastures, in stark contrast to the themes of loss and death, are in full blossom. These juxtaposed dynamics confirm rather than disavow the credibility of the story, because in the affect of it, we are reminded, even as death elbows its way to the forefront of consciousness, that hope is alive and well, busy springing eternal behind that shimmering veil. The bus arrives and drops her off, but by now it is early morning once again, and there is no transportation available to drive her the twelve miles to her final point of arrival. She decides to rest on the bench and wait until dawn, at which time when she plans to hire a car to drive her there. In the meantime, the local sheriff has received word about Mrs. Watts and when he locates her at the bus station, he informs her that her son and daughter-in-law are on their way to take her back to Houston. Now her anticipation is killed and her anxiety and disappoint peaks – she has come this far, only to be forced in the end to turn back. She won’t be able to realize this one last dream. She begs, pleads, and negotiates with the officer to please drive her the last twelve miles to Bountiful.  She gets herself so riled up, she has one of her ‘sinking spells’, becoming light-headed with blood pressure rising. He takes pity on her, yet feels it important to have her condition checked by the local doctor. (Considering that even at this point during the 1940’s heart disease is the number one cause of death in the United States, adding the ‘weak heart’ attribute was an effective device for heightening the tension for viewers of the film). After the town doctor examines her, making certain she not at risk for heart attack or death, he gives approval, and the sheriff decides to honor her request.

In the text The Last Dance: Encountering Death and Dying (DeSpalder and Strickland) the authors quote a source stating “one of the most important and unique aspects of human experience is the awareness of one’s own mortality” (p. 24).  This seems to be true of Carrie Watts who appears to have resolved the tensions one would naturally encounter in their final life stage. Having arrived at a point of realizing her fullest potential while honoring her life’s limitations, she accepts the fact that her resources, now spent, are beyond revival, and what’s left to accomplish is a panning review of her life efforts. Having justified the moral quality of her existence, she now desires to make peace with the ghosts of her past. Her attempt to return to Bountiful is a curtain call of sorts, beckoning her return to her roots, back to the same dust that was the substance and sum of her entire life, and in this sense she is already ‘living with an awareness of death’. Bountiful was the place that framed her most relevant life episodes, and encapsulated all her life seasons and cycles. It was the source of her psychic birth, and for her to come full circle, she needed for it to become the place of her psychic death. A return to Bountiful would provide her with the perfect place to ‘contemplate the basic questions’ of her existence that humans face as they near the end of life’s road (p. 25).

            Relevant to religious elements of thanatology in ‘The Trip to Bountiful’, Mrs. Watts, as a devout Christian formed in her youth by Bible Belt culture, has a strong devotion to hymns. The director chose the hymn “Softly and Tenderly”, weaving it like a strand throughout as a backdrop of the movie:

Softly and tenderly Jesus is calling, Calling for you and for me;
See, on the portals He’s waiting and watching, Watching for you and for me.

Come home, come home, You who are weary, come home;
Earnestly, tenderly, Jesus is calling, Calling, O sinner, come home!

Time is now fleeting, the moments are passing, Passing from you and from me;
Shadows are gathering, deathbeds are coming, Coming for you and for me.

This hymn parenthetically frames the context for the entire movie, and underscores its themes of homecoming, shadows gathering, deathbeds coming, and this is precisely brought to bear in the movie’s final scene.

            Contentedly, Mother Watts arrives at the doorstep of her precious Bountiful. She stands in front of it, assessing its current status: doors and windows now gone, empty of furniture, leaving a mere skeleton of a structure. Stepping into the empty house, Mother Watts surveys the now bare floors and walls. With her finger she retraces old scratches in the woodwork, and slides her palm across the dusty shelf of the mantle ledge imagining earlier times and remembering the objects that used to occupy the now empty spaces.

            Jostled from her reverie by the sound of Ludie’s voice calling ‘Mama! Mama!, Mother Watts goes to the porch and greets her son with sheepish face of a child caught with her hand in the cookie jar. “How do you feel?”, Ludie asks. “I feel much better son …. I got my wish!”. Once apologies are offered, the conversation turns to topics of the day, and Mother Watts, through misty eyes and averted glance relays how she just found out her young girlhood friend Callie Davis died the other day before she arrived. The funeral had been held the day before. Ludie apologies for not having brought his mother to Bountiful much sooner, stating that he just ‘thought it would be easier if we didn’t see the house again’. Mother Watts pushes past his denial saying, “Now that you’re here, don’t you want to come inside and have a look around?” Ludie declines saying “I don’t see much use in it; I’d rather remember it like it was”, implying that there was something unresolved from the past that he’d rather leave buried there. When Mother Watts asks Ludie if he remembers her father, Ludie launches into a tirade about how he remembers at age ten when he died and his grandfather’s best friend took him to his knee and told Ludie how his grandfather’s life was a real example to follow. Ludie’s grieving grandmother made him promise that when he grew up he would have a son and name him after his grandfather. However, Ludie did not have any children and he felt both ashamed that he was never able to keep that promise and that he never had any children at all, even though his friends went on to raise families themselves. This underscores the disappointment he must have carried throughout his entire life that he failed to measure up to an expectation set upon him at an earlier time of his life. However, a young boy could never predict how the vicissitudes of life would serve to interfere with even the best of intentions to fulfill those expectations. And so in this regard, the trip to Bountiful not only served Mother Watt’s need to find closure, but also the need for her son to find resolution and reconciliation, two themes that are present in thanatology as requirements for resolving the anxiety that surrounds death, ultimately leading to new paths of healing and hope.

            The story of The Trip to Bountiful was a shining example of Robert Kastenbaum’s Edge Theory and its Continuum of Awareness and Denial. Mother Watts, wanting to embrace the past, was situated on the Awareness pole of the spectrum, while Ludie leaned more toward the Denial end, as evidenced by his desire to avoid facing the past. What this movie shows us is that it is futile to resist the inevitability of death. That the sooner we recognize and accept that life, as the song says, is ‘fleeting, its moments passing from you and from me’, the sooner we can learn to welcome the inevitability of our own demise, and begin to cooperate and make peace with the process, rather than treat it as an eventuality to be denied and avoided.