The art of advocacy: strategies for psychotherapists.
Subject: Patient advocacy (Methods)
Patient advocacy (Management)
Psychotherapists (Practice)
Authors: Stewart, Tiffany A.
Semivan, Suzanne Gibson
Schwartz, Robert C.
Pub Date: 06/22/2009
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2009 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Summer, 2009 Source Volume: 12 Source Issue: 2
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 218313994
Full Text: ABSTRACT

Advocacy is a valuable tool for psychotherapists, both clinically and with regard to advancing the field. This article addresses the need for advocacy among psychotherapists, how advocacy is defined, and what roles psychotherapists can play when advocating. Advocacy strategies and skills are also outlined.

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The foundation of advocacy is rooted in actions taken by Clifford Beers, Lawrence Bernstein, and others (Kiselica & Robinson, 2001). Social justice concerns led Beers's efforts when fighting for the rights of mental health clients. This came as a result of Beers's personal experience of years spent in several mental institutions where he was horribly mistreated. The experience motivated Beers to enlighten others of what actually takes place behind the doors of mental institutions. Due to the efforts of Beers, it brought attention to an otherwise disaffected population. Efforts such as these led to the creation of organizations such as the National Alliance for the Mentally III and the National Mental Health Association.

For example, Lawrence Gerstein advocated for the exploited people of Tibet, an effort that focused on challenging human rights violations (Kiselica & Robinson, 2001). Violations such as cultural genocide, torture, imprisonment, and murder resulted in the people of Tibet having to leave their native land in immense numbers. Gerstein advocated on behalf of the Tibetan people by becoming involved in a campaign that raised awareness through what is currently known as the International Tibet Committee Movement, as well as establishing the Web site www.rangzen.com for the same purpose. His altruistic efforts have increased consciousness of the difficulty of the Tibetan people to bring about a social change. Advocates, through measures of caring and leadership, assisted in correcting conditions of social injustice. Essentially, advocating entails social change, accomplished in part by making public the implicit. This is often accomplished by means of illuminating social and political concerns at an individual, group, or societal level, while promoting a call to action.

Advocacy is identified as a central theme in psychotherapy (Field & Baker, 2004), with origins dating back to the inception of the field. Other early proponents in this area (e.g., Lee, 1998) cite advocacy as a process, which implies its dynamic and enduring nature. Specific to this process, advocacy utilizes a social action approach in psychotherapy, sometimes employing the distinct methods and techniques of psychotherapy to promote change in regard to injustice and inequality (Jackson, 2000; Mays, 2000; Strickland, 2000) or other issues relevant to clients or the profession. Although advocacy for clients has a long history, advocacy for the psychotherapy field itself has emerged as a phenomenon of the late 20th century, as it has had a direct effect on the evolution of mental health in this country (Sweeney, 1995). Over the past several decades, these efforts have resulted in more broad-based support of mental health within the general public, more stringent graduate program accreditation standards, increasingly rigorous requirements for national specialty certifications and state practice-oriented licenses (Chi Sigma Iota, 2007), and increased national-level parity of mental and physical health care coverage.

Advocacy can theoretically be viewed as the intersection of public relations, public policy, and conflict resolution (Eriksen, 1997). This vantage point of advocacy illustrates the stage, skill, and domain in which advocacy action is a part. The degree of expertise required for most advocacy efforts to achieve success, and the level of expertise needed, often relate to the specific domain in which advocacy is conducted. Consequently, advocacy action reflects a dynamic interplay between those who advocate, those for whom advocacy efforts are directed, and often a larger and more complex macrosystem.

Advocacy Defined

Bradley and Lewis (2000) defined advocacy as speaking up and taking action to make environmental changes on behalf of clients. Lee (1998) described advocacy as helping clients challenge institutional and social barriers that impede academic, career, personal, or social development. House and Martin (1998) identify advocacy as the belief that, to fight injustices, individual and collective actions that lead toward improving conditions for the benefit of both individuals and groups are necessary. However, the definitions, if accepted at face value, pose certain limitations to advocacy efforts in psychotherapy. For example, is advocacy always focused on client needs? Must advocacy efforts always relate to changing barriers and injustices? Do these definitions imply that psychotherapists are uniformly in positions of greater power compared to clients, and is this desirable? If advocacy is to be effectively incorporated into psychotherapists' repertoires, technical aspects of advocacy action should ultimately be understood broadly and inclusively.

One national accrediting body for mental health graduate programs defines advocacy as follows: "Action taken on behalf of clients and/or the counseling profession to support appropriate policies and standards for the counseling profession and promote individual human worth, dignity, and potential and to oppose or work to change policies and procedures, systemic barriers, long-standing traditions, or preconceived notions that stifle human development" (Council for Accreditation of Counseling and Related Educational Programs, 2001). This definition illuminates the importance in the idea that, as advocates, psychotherapists should seek to advance their field (rather than limit their efforts to specific clientele). This description also extends their roles as advocates to include that of social (i.e., policy and standards) change agents. Finally, the definition above addresses both the positive (i.e., promoting human worth and dignity) and the progressive (i.e., opposing and changing systemic barriers) aspects of advocacy.

However, one omission in the seemingly comprehensive definition above relates to the stance that as advocates, psychotherapists should seek positive change through actions within their professional roles. That is, when engaging in advocacy efforts as a psychotherapist, one's professional role as a mental health professional should be clear. Because potentially anyone can advocate for any cause (a process that most often occurs on the personal or lay level), as professional advocates, psychotherapists should maintain an awareness of their roles, purposes, and professional boundaries. Therefore, we define advocacy as change efforts aimed at supporting or promoting the growth and development of individual clients, groups, organizations, society, and/or the profession through goal-oriented actions. Such actions would be based upon identified or targeted concerns that relate to one's role as a psychotherapist.

As stated, advocacy is often identified as the collective, goal-oriented, multi-level actions that are proactively aimed at the advancement of individuals, programs, organizations, or communities (Semivan & White, 2006). Advocacy, as a core role in psychotherapy, is inclusive of and central to prevention, access, and provision of needed services and related professional or political activities that legitimize the actions of professionals. This idea is based upon the belief that all individuals have causes that they support and in which they believe. Some of the many types of psychotherapy advocacy efforts, from those that are individually to professionally based, include the following:

* Promoting an individual client's access to additional mental health services

* Helping to reduce the effects of prejudice and discrimination in an occupational environment

* Participating in a public seminar to promote understanding of psychotherapy services and the differences between mental health professions

* Contacting state legislators to voice support for a bill that enhances parity of mental health insurance coverage

* Supporting national campaigns (e.g., National Alliance for the Mentally Ill) aimed at reducing stigma of mental illnesses

* Serving on a professional committee focused on revising professional standards of practice or ethical codes

Thus, psychotherapists can advocate on many levels to promote the growth and development of individuals, groups, communities, and the field itself. By enhancing the lives of clients and their surrounding environments, psychotherapists can highlight the importance of mental health in general. By advocating for reimbursement parity of medical and mental health care coverage, psychotherapists can promote greater access to services. By demystifying psychotherapy for the public, psychotherapists can help legitimize and de-stigmatize mental health services.

Qualities of an Effective Advocate

This view of advocacy also acknowledges the major components of advocacy: knowledge, skill, passion, implementation, fact-finding, and data-based research (Semivan & White, 2006). Skills directed at addressing or instigating change rely upon a refined proficiency in communication, coupled with finesse in influence and persuasion, assertiveness and boldness, and a confident use of language accomplished in a professionally responsible manner. Advocacy can take place in a variety of ways. Effective advocates are knowledgeable about who they are professionally and what is meaningful to them, as well as how they may be able to advance the process in which they are advocating. In addition, it is essential that psychotherapists be aware of whom or what they are advocating. For example, important first steps may involve gathering the facts of the particular injustice you want to change, finding out how this injustice has wronged someone and to what extent, and who has been affected. Personal biases should be minimized in order to maintain objectivity.

Advocates should be goal-oriented and have concrete objectives. After obtaining facts, an advocate should make a plan that will spell out what steps need to be taken, as well as the resolution they wish to accomplish. This should be done systematically and strategically to ensure that actions will achieve the objectives. In order to challenge systemic barriers that block optimal mental health, a psychotherapist must be able to accurately perceive environmental influences on client development and possess skills to intercede at an environmental level (Lee, Armstrong, & Brydges, 1996). This may entail organizing the support of individuals and organizations who share the same viewpoint. A thorough understanding of action related to the target topic is subsumed under skills and knowledge. Interest and passion encompass the quality of investment, courage, ability, and willingness for risk-taking, as well as energy and genuineness of concern. Uniquely, advocacy action is individual and personal, and it is necessary to have a developed sense of self-knowledge, consciousness, and self-awareness. Self-awareness is an important consideration when evaluating one's individual strengths and weaknesses, as well as attitudes, values, beliefs, and biases that are finitely connected to activism (Kiselica & Robinson, 2001). A proactive, problem-solving approach will lead to successful advocacy action when combined with flexible thinking, realistic expectations, and an ability to have empathy for others, while in the process embracing divergent views and beliefs.

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Advocates should know the limits of their professional roles while possessing a secure professional identity. Professional level issues often transpire on larger levels and undertake mental health professional issues, which are greater in scope, both systemic and multilevel, and are viewed as collaborative (Eriksen, 1997). This requires a professional with an activist nature who can utilize advanced skills based in the knowledge, which are essential to address the intensity of an issue. Advocates should be open and amenable, so as to take in new information about a topic for which they are advocating. Additionally, as information frequently changes, advocates should be prepared to alter their perceptions of events. Because change may not occur as planned, having flexibility allows one to be accepting of changes at all levels. Finally, empathetic understanding and listening play a valuable role in the advocacy process and are critical to one's ability to understand and identify with those you are advocating.

Advocacy as it Relates to Psychotherapy

The goals of psychotherapy related to promoting the field and serving a diverse client base are part of the aim of professional advocacy, and these particular efforts are often directed at the needs of clinicians, as well as persons within the community. Although mental health professionals can at times receive reimbursement for advocacy efforts (e.g., when advocating for a client during normal business hours), psychotherapists who advocate on behalf of a cause usually do so voluntarily as opposed to on a paid professional basis. Further, advocacy is seen as a professional and ethical responsibility (D'Andrea & Daniels, 1999) psychotherapists have in taking action toward improving the rights of socially devalued persons, reducing inequities and barriers to the prosperity of individuals, or promoting the livelihood of mental health professionals. For example, the American Counseling Association has recently endorsed the following set of Advocacy Competency Domains (Lee, Arnold, House, & Toporek, 2003) for mental health professionals in an attempt to specify different modes of advocacy: direct intervention, environmental intervention, systemic change of leadership, informing the public, and influencing public policy. Direct intervention refers to client or student empowerment, which promotes self-advocacy and human growth factors where social, political, economical, and cultural factors are taken into consideration. Environmental advocacy intervention efforts occur after psychotherapists have been made aware of impediments that have resulted in an individual's development or life experience. Systems-change leadership occurs when psychotherapists challenge the status quo and attempt to change the day-today processes of identified systems. Social-political advocacy involves psychotherapists attempting to foster change in areas that impact and influence their own students or clients directly.

As professionals have embraced various causes throughout the mental health movement, they have searched within themselves to find goals that have personal worth and have developed a moral urgency that has shaped their advocacy actions (Kiselica & Robinson, 2001). Promoters of advocacy have endorsed it as a strategy, comprised of a two-pronged and multileveled model illustrating advocacy action for clients and for the profession (Meyers & Sweeney, 2004). For example, client-based advocacy necessitates giving a voice to marginalized clients who would otherwise not have one, and in doing so, placing client welfare as paramount (Lewis, Cheek, & Hendricks, 2000). From a professional standpoint, many mental health professionals are gaining an awareness that advocacy work is required outside the confines of the office (Lewis et al., 2000), and advocacy, on all levels, potentiates psychotherapists' motivation to strive for causes larger than themselves (Meyers & Sweeney, 2004). Consequently, the roles of advocates are markedly different from other professionals who influence others on an individual, group, state, or national level.

While advocacy involves changes aimed at growth and development through outcome-based efforts, it should be distinguished flora teaching, supervision, consultation, and clinical practice. Although these different professional roles can be interrelated, there are some distinct differences among them. First, advocacy is an explicit (or implicit) contract that involves a conscious effort from the advocate. The focus is typically on a third party, which may or may not involve a client. An advocate characteristically does not need to possess any client or consultee-specific skills, and unique ethical codes or guidelines may apply.

While clinical practice is a direct therapeutic relationship involving the psychotherapist and client, the goals are treatment-oriented and direct, as opposed to the indirect (i.e., third party) efforts drawn upon in higher levels of advocacy. Hence, in clinical practice, once a professional relationship has begun, a legal duty has been initiated by the psychotherapist. This is not the case during the initiation of advocacy efforts.

In supervision, there is a hierarchical relationship between the psychotherapist and supervisee, which is evaluative in nature. This differs from advocacy in that advocates usually do not evaluate other professionals from a learning perspective. Supervision usually takes place in a professional developmental training setting, whereas advocacy efforts may involve a diverse range of environments. The supervisor is charged with training considerations that will help the supervisee to expand his or her practice to include advocacy action and the skills necessary to have the ability to confront entities that oppress clients (Lewis et al., 2000). In the development of supervisees, supervisors usually focus on building therapy competencies and promoting identity development in supervisees (Ladany, Friedlander, & Nelson, 2005). Advocacy is not typically involved in the direct professional development of psychotherapists.

Similar to supervision, teaching is also hierarchical in nature. However, teaching is more systematic and planned, involving more formal evaluations, and has specific predetermined goals and objectives. In a teaching role, the educator is responsible for what the student is required to learn and has the duty of assessing the students' level of performance. Compared to teaching, advocacy is usually not as formal, and it does not involve standardized lessons and evaluation processes inherent in teaching. Whereas in consultation the emphasis is on a third party (similar to advocacy), consultants frequently focus on enhancing the functioning of a client or worker. Although the consultant relationship is not hierarchical, it typically involves professional colleagues who desire or are in need of assistance. A formal consultation role or process commences (often with a contract) and is usually geared toward specific professional skill deficits to help the third party; it is in this way that consultation differs from advocacy. As a consultant, the psychotherapist uses professional abilities, insights, and judgment in a collegial manner, sharing in the responsibilities of learning with the third party (Lewis et al., 2000). Unique ethical codes or guidelines different from those followed by advocates usually apply to consultation as well.

Practical Advocacy Strategies for Psychotherapists

Structurally, advocacy is a multi-level, interactive, and multidirectional process that must take contextual factors into account. Therefore, advocacy actions range from the simple to the complex and, in general, a greater skill repertoire is necessitated as one's advocacy efforts reach larger systems or constituencies. However, regardless of the scope of advocacy actions, certain core strategies should be included and, if understood and used throughout the advocacy process, will help increase one's chance of success. Advocacy strategies should be planned and coordinated so an advocacy project can lead to a positive mental-health-related outcome (i.e., benefit clients, the profession, and/or society as a whole). Advocacy strategies, therefore, can best be viewed in terms of the specific steps needed to achieve the advocacy goals:

1. The psychotherapist must be able to identify the target population that will be the focus of his or her advocacy efforts. This includes the identity, location, nature of injustice (if applicable), and the extent of the issues of the target audience.

2. Consider honing a rationale for why the population and issue have been chosen. This could include how it affects the advocate personally or the importance of how these efforts will affect a larger target population.

3. Describe the specific problem or issue that you believe should be addressed by psychotherapists and how advocating for the particular cause fits the psychotherapist's role. It is helpful if the problem identification is clear and concise, so that concerns and objectives are understood. A critical component of this step is making sure that the problem to be addressed remains within the scope of competence for the psychotherapist.

4. Identify problem background information. This step is accomplished by considering the personal (e.g., client) or social (e.g., community) need for advocacy in a particular area. This information may be found in literature or other resources available on the issue, by speaking with individuals who have been directly affected, and by identifying perceptions about the current situation. During this stage it is often beneficial to include a list of advocacy efforts previously conducted or currently being conducted. The 'problem' can be viewed as limitations or deficits in access, understanding, or acknowledgement of needed services or interventions. Once the problem background is fully understood, it can help advocates better determine how to find resources needed to initiate change.

5. An accurate account of references or resources that have been used is needed to identify the source of your information should others need it, as well as to provide authenticity of the issue. A list of resources can also aid others, should the advocate be asked to provide follow-up information.

6. Goals should describe the broad, overall intent, moving toward the ultimate goal(s) related to the advocacy project. For example, what role will the psychotherapist play in reaching these goals? What is the outcome hoped for if the advocacy goals are achieved? Goals should be measureable so the advocate can ascertain whether he or she is moving closer toward the goal attainment as the effort progresses. Goals may need to be reviewed regularly, as they may need to be redefined and restructured according to need.

7. After goals have been carefully selected, determining interventions is necessary in order to begin the project. "What are the first steps toward realizing the goals?" and "What psychotherapy-related skills are needed to begin?" are good questions for the advocate to ask himself or herself. The advocate should then begin intervening, taking into account the information and resources accumulated thus far.

Risks and Limitations Associated With Advocacy

As described above, advocacy in action can have many benefits. However, advocacy efforts also have risks and limitations. It is important that psychotherapists are knowledgeable about the potential 'negatives' associated with advocacy. In this way, psychotherapists can 'begin advocacy actions with their eyes open' and potentially prevent unnecessary risks during the advocacy process. The following are some risks and limitations inherent in many forms of psychotherapy advocacy:

Time: Advocacy actions are often time intensive; however, they are also capable of producing great rewards. Change may not happen immediately and on the schedule in which advocates have planned. Hence, one should be flexible enough to allow the necessary time that may be needed. In order to persuade others to change, one should be flexible and willing to change and compromise as well (Ponzo, 1974). Psychotherapists should also consider that it takes time to learn the art of advocacy. In this regard, trial and error may be required while building knowledge, skill, and self-awareness related to effective advocacy strategies.

Ongoing effort: Advocacy is an effort that involves thought, planning, and passion. Ali of these may be ongoing, as they may need to be restructured and redirected at times. A psychotherapist's passion for the cause they are involved in can aid in the longevity of an advocacy action plan.

Emotional demands: Advocacy can be demanding as personal resources become strained. These demands also include the emotional cost involved in taking up a cause and investing the energy in seeking or promoting change. Emotions often encountered during advocacy efforts include fear of reprisal, confusion about the next step, guilt about not being able to do more, helplessness when roadblocks are confronted, and anger when advocacy efforts seem to be hindered by others (Semivan & White, 2006).

Relationship vulnerability Relationships may be threatened when advocacy efforts result in confrontation of negative professional or systemic situations. It is not uncommon for an advocate to be viewed as a troublemaker (Kiselica & Robinson, 2001). It is also possible that harassment from adversaries may take place (Dinsmore, Chapman, & McCollum, 2000). Depending on the cause, advocacy may also spill over into the personal life of the advocate, possibly jeopardizing one's personal relationships, especially when others do not share the same views (Lee & Walz, 1998).

Job stress: Similar to relationship vulnerability, job stress may involve the political fallout that may be suffered if employers do not share the same views as the advocate. A troubled reputation could lead to professional backlash, which can endanger job stability. Pleading for an unpopular cause may result in being ostracized professionally (Lee & Walz, 1998).

Role confusion: It is imperative during advocacy efforts that the psychotherapist is accurately aware of the cause, who is being affected, and how they may be of assistance in making a positive change without stretching ethical limits. Psychotherapists must keep in mind that they are required by ethical considerations to know their professional limitations. Ultimately, the focus of advocacy efforts should be to provide others with the tools needed to challenge the status quo on their own.

Conclusion

The stewardship inherent in being an advocate sets one's individual and professional actions across the backdrop of countless afflicted individuals who have suffered inequity. This image expectantly causes some impact as to the exigency of advocacy actions required to remediate access, barriers, or injustices faced by clients, or in the psychotherapy field. In its origins, advocacy actions were born out of the efforts of dedicated professionals, whose awareness of the barriers and injustices faced by clients activated their moral compasses. Their sensitivity to the human condition led them to pursue information and solutions so that their actions would impact the circumstances faced by individuals, groups, and communities.

As described above, the nature of advocacy action is complex, and it is commensurately more involved as one goes from the individual to the systemic domain. Furthermore, as defined, advocacy aims are designed to instigate changes from the client level to the professional level. Some ideas related to strategic advocacy have been provided, so that efforts influencing individuals or the psychotherapy field can be viewed as attainable and characteristic of successful advocates. Also, considerations are provided regarding the intricacies of advocacy roles in order to help ensure success. A call to action has been made so more artful and impactful advocacy can be performed by psychotherapists. It is hoped that the employment of strategies and skills suggested within this article will produce a matching sense of accomplishment that previous advocates have described with enthusiasm.

This article is approved by the following for continuing education credit: The American Psychotherapy Association provides this continuing education credit for Diplomates.

After studying this article, participants should be better able to do the following:

1. Understand the definition and scope of professional advocacy.

2. Gain knowledge about types of advocacy.

3. Learn how to plan advocacy efforts.

4. Understand the benefits and risks of professional advocacy.

KEY WORDS: advocacy, social justice, social action, client empowerment

TARGET AUDIENCE: psychotherapy professionals

PROGRAM LEVEL: Basic

DISCLOSURE: The author has nothing to disclose.

PREREQUISITES: None

Earn CE Credit

Take CE tests for free online at www. americanpsychotherapy.com or see line questions for this article on page 60.

POST CE TEST QUESTIONS (Answer the following questions after reading the article, pages 54-59)

1. Which of the following describes the correct planning sequence of advocacy actions?

a) identify the problem, gather resources, set advocacy goals.

b) Accumulate resources, identify the problem, begin advocacy interventions.

c) Learn about the target population, gather resources, set advocacy goals.

2. Which of the following correctly identifies how advocacy is different from teaching, supervision, and consultation?

a) Teaching is more hierarchical in nature, involving more structured/planned activities.

b) Supervision focuses more on empowering third parties, while pleading for a cause in order to bring about social change.

c) Consultation involves working directly with clients or consumers in order to promote mental health or quality of life.

3. Which of the following is true regarding professional advocacy?

a) Unique ethical codes usually do not apply during professional advocacy.

b) Advocacy actions con be focused on individuals, groups, communities, or the psychotherapy profession.

c) Advocacy among psychotherapists is uncommon and rarely needed.

4. Which of the following describes a comprehensive definition of professional advocacy?

a) Actions taken on behalf of individual clients in order to end social injustices and other impediments toward human development.

b) Change efforts directed toward the growth and development of the profession, including actions toward promoting psychotherapy.

c) Change efforts aimed at promoting the development of individual clients, groups, organizations, society, and/or the profession through goal-oriented actions.

5. Which of the following are not described by the literature as qualities of effective advocates?

a) Being systematic, strategic, and assertive.

b) Demonstrating a willingness to engage in conflict when needed.

c) Showing self-awareness, flexibility, and diplomacy

6. The casts involved in taking up a cause, often resulting in fears of reprisal and guilt about not being able to do more, relate to which of the following 'risks of advocacy'?

a) Extended time

b) Relationship vulnerability

c) Emotional demands

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By Tiffany A. Stewart, M.S., Suzanne Gibson Semivan, M.S., and Robert C. Schwartz, Ph.D.

Tiffany A. Stewart is a doctoral candidate in Counselor Education at the University of Akron. Her research interests include Multicultural Counseling and Mentorship.

Robert C. Schwartz has a doctorate in Counselor Education from the University of Florida. He is currently an Associate Professor in the Department of Counseling and Director of the Clinic for Individual and Family Counseling at the University of Akron. He is a Licensed Professional Clinical Counselor in the State of Ohio. His research/clinical interests include depressive and personality disorders, schizophrenia, and Eastern approaches to healing.

Suzanne Gibson Semivan is a doctoral candidate in Counselor Education and Supervision at the University of Akron. She is currently the Director of the Thiel College Counseling Center and an adjunct faculty member at Youngstown State University. Her research interests are supervision, advocacy, microskills training, and college counseling.
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