Volume 37/Number 2/April 2015/Pages 152-163

Integrating Health and Wellness in

Mental Health Counseling: Clinical,
Educational, and Policy Implications
Sejal M. Barden
Abigail H. Conley
Mark E. Young

A 16-year-old girl approaches the school counselor with an idea. She and a
friend want to start a support group for overweight girls who wish to lose weight. A
mental health counselor in private practice sees a new client who was referred for
depression and anxiety. The client mentions that she had coronary bypass surgery
a year ago and has not been taking her antidepressant medication, relying instead
on herbal medicine. At a Veterans Affairs Center, a 26-year-old veteran of the Iraq
War comes in for a checkup. Diagnosed with post-traumatic stress disorder after
his vehicle was hit with a rocket-propelled grenade, he still has nightmares but is
more concerned about frequent headaches and depression. In all three of these
cases medical problems and mental health issues intersect.
We use these examples to examine how counselors today need to treat
clients with interacting medical and mental health issues. First, obesity is
definitely on the rise among children and teenagers (Ogden, Carroll, Curtin,
Lamb, & Flegal, 2010). About 17% of those between the ages of 2 and 19 are
obese, and the representation of minorities is disproportionately large (see
McElroy, Allison & Bray, 2006; Simon, Von, & Saunders, 2006). Moreover,
although programs for preventing obesity have proved to be effective (Veugelers
& Fitzgerald, 2005), counselors of children and adolescents receive virtually no
training in working with overweight students (Choate, 2008).
Meanwhile, more Americans than ever before are surviving cardiac arrest
and it can leave psychological scars (Wilder Schaaf, et al., 2012). Postsurgical

Sejal M. Barden and Mark E. Young are affiliated with the University of Central Florida and Abigail H.
Conley with Virginia Commonwealth University. Correspondence about this article should be addressed
to Dr. Sejal M. Barden, College of Education and Human Performance, University of Central Florida, P.O.
Box 161250, Orlando, FL 32816-1250.Email: Sejal.Barden@ucf.edu.

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Journal of Mental Health Counseling

Health and Wellness in Mental Health Counseling

Few counselor training programs offer wellness courses or training on how to ethically and
competently integrate physical and mental health issues when working with clients. This article
highlights the interrelatedness of mental and physical health to build on the counseling professions own tradition of wellness and to encourage mental health counselors and counselor
educators to adapt to changes in integrated healthcare. We propose that the mental health
profession adopt competencies for wellness as part of standard counselor preparation and continuing education.

Health and Wellness in Mental Health Counseling

depression has been found in about 25% of coronary bypass patients (see
Krannich, Weyers, Lueger, Herzog, Bohrer, & Elert, 2007). Women and older
clients are more susceptible to such depression (Doering, Magsarili, Howitt, &
Cowan, 2006). Although it is declining in favor of angioplasty, more than 1 million Americans still have bypass surgery every year (Epstein, Polsky, Yang, Yang,
& Groeneveld, 2011). It is therefore imperative that mental health counselors
understand the connection between surgical procedures and mental health.
According to the Centers for Disease Control and Prevention (CDC;
2013), every year 2.5 million Americans visited an emergency department or
were hospitalized because of traumatic brain injury (TBI). Such injuries can
impair physical, cognitive, emotional, intellectual, and behavioral functioning.
The total number of U.S. military personnel diagnosed with new cases of TBI
has risen from about 10,000 per year in 2000 to about 18,000 in 2014 (Military
Health System, 2014), totaling over 300,000 cases of veterans diagnosed. In
the United States, TBI is the leading cause of death and disability from ages 1
to 44. (Gilchrist, Thomas, Xu, McGuire, & Coronado, 2011). Many cases of
mild traumatic brain injury also go unrecognized, as most concussions occur
without loss of consciousness (Jones, Young, & Leppma, 2010). Symptoms of
TBI, which range from mild to severe, include fatigue, poor concentration,
emotional changes, depression, memory problems, anxiety, and posttraumatic
stress. The correspondence between TBI and mental health symptoms highlights the need for counselors to be able to recognize when individuals are
suffering from TBI.
A WELLNESS ORIENTATION

Within the mental health professions, wellness has been defined as a way
of life oriented toward optimal health and well-being, in which body, mind,
and spirit are integrated (Myers, Sweeney, & Witmer, 2000, p. 252). Although
in theory the counseling profession is grounded in a wellness orientation
(Council for Accreditation of Counseling and Related Educational Programs,
2009; Kaplan & Gladding, 2011; Witmer, 1985; Wolf, Thompson, & SmithAdcock, 2012), counselors may not actually be competent to help these clients
because they are not trained in the biological bases of behavior and thus not at
the forefront of the emerging treatment and prevention healthcare paradigm
(Choate, 2008; Granello, 2012). This article highlights the increasing need for
mental health counselors to conceptualize client issues within a biopsychosocial framework; reviews the history and current trends in wellness; and suggests
competences that will enable counselors to apply their wellness orientation
when working with clients. Throughout we use the term biopsychosocial to
illuminate the interaction between biological, psychological (thoughts, emotions, behaviors), and social (socio-economic, socio-environmental, cultural)
factors. The next section reviews research supporting the need for counselors
to consider how all three factors relate to conceptualizing and treating mental
health issues.

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INTERSECTION BETWEEN PHYSICAL AND MENTAL HEALTH

Advances in biomedical science, pharmacology, and neuroscience have

significant implications for helping professionals (Plomin & Crabbe, 2000).
Mental health practitioners routinely work with clients with co-morbid physical and mental health problems, although they may have limited training in
understanding the connections between biological, psychological, and social
dimensions of health and illness. The World Health Organization (WHO,
2011) estimates that 14 percent of global diseases are a result of neuropsychiatric disorders, primarily depression, bipolar disorder, use of alcohol and
controlled substances, and other common mental health issues. For example,
depression has specific physical effects, such as changes to serotonin metabolism (alteration of cardiac function, vasoconstriction); cortisol metabolism
(higher levels of cortisol leading to inflammation); inflammatory processes
(predictive of cardiovascular disease); and cell-mediated immunity (impairment of T-cells, which affect cancer and HIV and other infectious diseases).
Mental health issues are also directly related to long-term disability, dependency, mortality, and other health conditions (WHO, 2011).
In a meta-analysis (k = 22) of the influence of mental health on physical
health, Jonas and Mussolino (2000) found 15 studies that reported strong associations between depression, anxiety, and coronary heart disease, highlighting
that depression was a serious risk factor for both fatal and nonfatal strokes.
Mental health issues may also adversely affect treatment adherence and the
ability to engage in activities to prevent disease, promote health, and strive
toward optimal wellness (Prince et al., 2007). Therefore, it is imperative that
mental health practitioners be knowledgeable about the interaction between
mental and physical health symptoms and be able to use an integrated perspective to tailor treatment and interventions.
One area where biology and mental health intersect is pharmacotherapy
for mental disorders. A study of antidepressant use from 2005 to 2008 (Centers
for Disease Control [CDC], Pratt, Brody, & Gu, 2011)) found that more than
1 in 10 Americans aged 12 and above reported taking an antidepressant. Given
the frequency of persons taking medications to alleviate mental health symptoms, it is vital that counselors understand how medication influences clients,
when their medication needs to be reassessed, and how to work with the prescribing professional. Ingersoll (2000) supported the need for counselors to be
trained in psychopharmacology, now that more psychotropic medications are
available for clients than ever before.
The need for more formal training in psychopharmacology has been
debated for nearly 30 years. Ponterotto (1985) was the first to propose that counselors become familiar with current medications. Two decades later, Kaut and
Dickinson (2007) asserted that counselors were still challenged to understand
the potential benefits and limitations of numerous types of drugs. Council
for the Accreditation of Counseling and Related Educational Programs
(CACREP; 2009) standards have since substantiated the need to understand
psychopharmacological medications and related contraindications.

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Health and Wellness in Mental Health Counseling

Although researchers like Kaut & Dickinson (2007) recognize interactions between biological and psychological causes of health and disease,
mental health professionals often conceptualize disorders dualistically as either
physical or mental (Bloom, 2004). This either/or perception has serious clinical implications. Miresco and Kimayer (2006) found that clinicians tend to
blame clients more when they consider symptoms to be psychological rather
than biological. Other scholars (e.g., Goldstein & Rosselli, 2003; Kuppin &
Carpiano, 2006) have found that laypeoples beliefs about the biological basis
of mental disorders tend to influence their beliefs about their curability and the
efficacy of treatment modalities (medicine or therapy). A patient who views a
disorder as biologically based may be more inclined to adhere to treatment. A
client who believes the disorder to be more psychologically based is less likely
to adhere to medical treatment and more likely to accept behavioral interventions (Ahn, Proctor, & Flanagan, 2009). Mental health professionals may also
have the same biases. In short, besides knowledge, counselors may need a shift
in attitudes about the causes and prognosis of disorders if they fail to see multiple causes and exacerbating factors.
However, believing that all psychological issues are grounded in biology
is a reductionist perspective that has limited clinical utility (Granello, 2012).
Rather, counselors are encouraged to see biological and neurological factors as
influencing human behavior, given the professions holistic wellness-oriented
approach to mental health (Kaplan & Gladding, 2011; Witmer, 1985; Wolf
et al., 2012). Nevertheless, what is needed is commitment to curricular and
philosophical responses to the emerging healthcare paradigm. Consider, for
instance, the definition of counseling on the American Counseling Association
website: Professional counseling is a professional relationship that empowers
diverse individuals, families, and groups to accomplish mental health, wellness,
education, and career goals (Kaplan & Gladding, 2011). But can counselors
effectively support a wellness philosophy and holistic approach to mental health
without a fundamental understanding of how the mental and biological dimensions of health are interrelated? We believe it is imperative for counselors to
understand both the biological and the psychological bases of mental health so
that they can effectively and ethically practice a wellness approach.
HISTORY OF WELLNESS IN COUNSELING

One of the primary distinctions between counselors and other mental

health professionals has been an emphasis on wellness and holistic care for
clients (Hanna & Bemak, 1997, Mellin, Hunt, & Nichols, 2011). In their 2011
study, Mellin and colleagues conducted a qualitative investigation (N = 238) of
counselor professional identity. They found that counselors in general believed
their professional identity to be grounded in developmental, prevention, and
wellness orientations. Furthermore, counselors believed in constructing treatments and interventions from strength-based approaches rather than more traditional approaches focused on mental illness or pathology (Mellin et al., 2011).

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Wellness-oriented practices in the medical arena also date back to the

1970s, when researchers began to recognize that psychological stress and physical
complaints were related. Stress is still a factor for 6080% of patients who seek
help from their primary care physicians (Nerurkar, Bitton, Davis, Phillips, & Yeh,
2012). This realization in both the scientific community and American society
spawned a line of research that implicated stress in such ailments as headaches,
rheumatoid arthritis, and cardiovascular disorders. Simultaneously, researchers like Herbert Benson at Harvard University identified unique physiological
changes produced during meditation (Myers & Benson, 1992). The Menninger
Hospital began to study yogis who could alter their body temperature, heart rate,
and other autonomic responses. The idea that individuals could consciously
change their physiological reactions was a revelation not only to medicine but to
those in mental health care. One of the first innovations was biofeedback, which
gave clients access to moment-by-moment measurements of their galvanic skin
response, muscle tension, and breathing so that they could control them.
In response to this stress revolution, workshops sprang up around the
country to help people learn skills for combatting the deleterious effects of stress
(Folkman & Lazarus, 1980). Many companies and workplaces hired counselors
and other mental health professionals to help their employees deal with the
menace of stress and its accompanying physical symptoms. These workshops
often asked participants to fill out the Social Readjustment Rating Scale (Holmes
& Rahe, 1967), a measure that linked stress to both positive and negative change
events that had occurred in the past year. Often the alarming results showed that
participants were at risk of physical or mental calamity. Although these conclusions were based on nonsignificant statistical findings, they resonated with the
growing understanding that psychological stressors and illness were connected.
While psychologists were developing the field of health psychology (Wingard,
Berkman, & Brand, 1982), medical professionals were beginning to use the term
wellness to describe the positive state of health alluded to in the 1946 definition
put forward by the United Nations, which described wellness as a state of complete physical, mental, and social wellbeing and not merely the absence of disease
or infirmity (see Callahan, 1973, p. 77). Counselors adopted this term because
it harmonized with many of the founding principles of the ACA, including a
humanistic vision of the whole person operating at full potential (Witmer, 1985).
In the early 1970s, J. Melvin Witmer, professor of counselor education
at Ohio University, presented one of the first wellness classes, Stress and
Biofeedback. Given previous research and growing recognition of the relation
of stress to wellness, in 1975 Witmer opened a biofeedback and stress management lab at the university, taught workshops nationwide, and directed 14
doctoral dissertations related to stress and wellness. He constructed a model of
wellness and an assessment inventory (Wel Inventory) that identified 14 different areas of functioning, from self-regulation to exercise (Witmer & Sweeney,
1992). Through the efforts of his colleagues, Jane Myers and Tom Sweeney, the
inventory and the wellness model were promulgated. Myers and Sweeney have
continued to publish in the area of wellness, leading the movement in wellness

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Health and Wellness in Mental Health Counseling

research for the past two decades and refining the original inventory into what
is now called the Five Factor Wellness Inventory (Myers & Sweeney, 2005).
However, although they and others have continued to educate and
research wellness-related issues, little has been done to incorporate their recommendations into formal training or counselor preparation accreditation
requirements. Yet it is our responsibility as counselors to anticipate the future
and, although there is no guarantee our predictions will be accurate, prepare
future counselors with the skills they need to practice ethically within the
emerging health care paradigm.
CURRENT TRENDS IN WELLNESS AND HEALTHCARE REFORM

New emphasis on healthcare reform has again brought the concept of

wellness to the forefront. A healthier population (with, e.g., lower morbidity
rates, lower healthcare costs, and higher workforce productivity) brings economic benefits for both individuals and companies. Passage of the Patient
Protection and Affordable Care Act (PPACA, 2010) should reinvigorate counselors to advocate, both for the profession and for clients, for access to services,
reimbursement, prevention of chronic disease, and improving public health.
The legislation mandates that as of 2014, mental health and substance use
disorder services will be among the health care categories that must be covered
by all insurance policies offered through the exchanges and Medicaid (PPACA,
2010). In addition, more people will become eligible for Medicaid or will be
able to buy affordable coverage, and insurers cannot exclude substance abuse
or mental illness by labeling them pre-existing conditions. Insurance companies must also cover preventive services, such as screening and counseling for
alcohol and other drug misuse, diet and obesity, and domestic and interpersonal violence (PPACA, 2010).
Medicare is another example of a growing market where counselors should
advocate for their services. Medicare covers about 39 million Americans aged
65 or older and another 8 million with disabilities (Centers for Medicare and
Medicaid Services 2013). Decades ago, the Omnibus Budget Reconciliation
Act of 1987 recognized psychologists and clinical social workers as independent
mental health providers, but counselors are still not fully recognized (Karlin &
Humphreys, 2007). The Seniors Mental Health Access Improvement Act of
2013 was introduced to the Senate in an attempt to extend Medicare reimbursement to licensed professional counselors and marriage and family therapists, but
the bill has since not moved. Thus, while some changes have been made that
benefit mental health counselors, much work is still needed to advocate for more
equitable coverage. Besides inclusion in federal programs, counselors need to
be better integrated into the healthcare system generally to improve transitional
care, ensure client welfare, and help lower healthcare costs. In fact, the United
States Department of Health and Human Services (HHS) has endorsed a
patient-centered medical home model to reorganize primary health care to focus
on (a) comprehensive care that integrates physical and mental health care needs;

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(b) patient-centered treatment; (c) coordinated care across the entire healthcare
system; (d) accessible services; and (e) quality and safety (Andrews et al., 2014).
In hospitals there is a trend for Medicare reimbursement to the provider to
be reduced if the patient is readmitted within 30 days of discharge, as happens
in about 20% of Medicare cases (Epstein, Jha, & Orav, 2011; Jencks, Williams
& Coleman, 2009). Researchers (e.g., Epstein et al., 2011; Jencks et al., 2009)
showed that common reasons for readmission related to patient compliance,
strained resources, coexisting conditions, and transitions to life after the medical event. This gap between medical diagnosis and patient compliance is fertile
ground for counseling professionals to work with both patient and healthcare
provider to improve patient wellness, reduce health care costs, and create job
opportunities for counselors in the medical field.
In sum, changes in healthcare demand more training for counselors and
underscore the need for continuing education to prepare counselors to work
within systems that recognize the relationships of physical and psychological
issues. As yet mental health professionals have very little training in, or understanding of, biological and wellness issues that are central to competent treatment. Scholars have promoted distinguishing counselor professional identity
from that of other helping professions because of its focus on developmental,
prevention, and wellness orientations (Eriksen & Kress, 2006; Granello &
Young, 2012; McAuliffe & Eriksen, 1999). Yet the counseling profession has
failed to emphasize wellness, as evidenced by an absence of competencies and
a dearth of such course offerings in counselor preparation programs. In what
follows we offer proposals for such wellness competencies.
WELLNESS COMPETENCIES

Identifying professional competencies allows professions to establish

standards of practice, measure performance, demonstrate accountability, and
improve quality and effectiveness. That is why we suggest specifying wellness
competencies or minimal standards of knowledge and skills. For example,
based on a summit that took place in 2007, France and colleagues (2008)
proposed competencies for clinical health psychology. While not directly transferable to counseling, the competencies they set forth identify several domains
that may guide identification of counselor wellness competencies.
Five Categories of Competence
The five health psychology competencies relate to assessment, intervention, consultation, research, and supervision competencies. The categories
guided development of the wellness competencies discussed here.
Assessment competencies include knowledge of and the ability to administer and interpret biological, psychological, and social-environmental assessments; conduct biopsychosocial interviews; assess physical risk factors; gauge
environmental barriers; assess adherence to treatment and the impact of medical procedures; understand ethical and legal repercussions of assessment in
health care; and use emerging health assessment technologies.

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Intervention competencies include understanding the causes and progression of disease and current treatments and psychological factors in illness and
health behavior; identifying social-environmental issues that affect treatment;
and use of evidence-based treatment methods targeted to the population.
Those competent in intervention must also be skilled in health promotion and
prevention, be able to monitor and adjust treatment, and understand ethical
and legal issues in healthcare.
Consultation competencies include the ability to consult with medical
personnel, understand medical terminology, be familiar with the literature, and
be able to operate in a medical environment and encourage cross-disciplinary
understanding (Ruddy, Borresen, & Gunn, 2008).
Research competencies include knowledge of health behaviors and health
outcomes and understanding of diverse research methodologies and strategies
for analyzing data related to health promotion.
Supervision competencies require supervisors to have knowledge of the
kinds of trainees and professionals that work in healthcare settings and their
roles and skills; be able to instruct and supervise students in training; and be
able to train students to advocate for their professional autonomy and identity
while respecting other professions.
While these are helpful in guiding the drafting of counseling competencies, they must be adapted to highlight the distinctions between counselors and
psychologists.
Proposed Competencies for Wellness Counseling
Promulgating competencies can improve counselor preparation and continuing education by recognizing the importance of staying current with the
kinds of skills and knowledge that counselors need in order to provide ethical
and competent services. Based on the competencies put forward by France et
al. (2008) and the work of Granello (2012), Witmer and Granello (2005), and
Myers (1991), we propose the following preliminary competencies for assessment and treatment in wellness counseling. We are not advocating for a specialty or a separate degree program but rather for a curriculum integrated into
a single course or infused into several (see Witmer & Granello, 2005, for a discussion of both approaches). We propose that by the end of their initial training
professional counselors should possess the following minimum competencies:
Assessment
1. Knowledge
a. Understand the foundation of counseling as an integrated model of
biological, psychological, and social/relationship dimensions.
b. Demonstrate comprehension of and ability to evaluate medical
terminology, medical procedures, and the results of medical tests.
2. Skills
a. Conduct comprehensive biopsychosocial interviews and evaluate
interactions between biological and psychological findings.

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b. Recognize and evaluate client counseling needs while integrating disabilities, illnesses, or injuries with strengths, resources, and supports.
c. Assess a clients compliance with medical and counseling treatments and gauge the effect of the economic/social/cultural environment on the clients ability to engage in treatment.
d. Help clients understand the value and purpose of medical testing.
Treatment
1. Knowledge
a. Be thoroughly familiar with the most current evidence-based
treatments and the efficacy of counseling interventions on health
outcomes.
b. Understand the causes and treatment of major medical diseases and
how they interact with mental and sociocultural stressors.
c. Recognize environmental and social factors that interfere with client engagement in healthy and wellness behaviors.
d. Recognize biological responses to pharmacology and psychotropic
medications and the influence of such medications on client functioning.
e. Be knowledgeable about which complementary and alternative
medicines, such as meditation, herbal treatments, acupuncture, and
diet, are effective and which ineffective.
f. Be familiar with the most effective methods for dealing with counseling issues associated with traumatic medical events and have the
ability to help clients deal with grief, the dying process, and death.
g. Know which methods of prevention and health promotion have
proven effective.
h. Keep up with emerging technologies to help clients to monitor and
change health behaviors.
2. Skills
a. Use evidence-based health and wellness counseling practices that
take into account the clients stage of change and cultural, religious,
or spiritual background attitudes and values.
b. Demonstrate ability to work as a team with other healthcare providers.
c. Use emerging technologies to help clients monitor and change
health behavior, such as exercise, diet, and smoking.
CONCLUSION

Let us return to the three cases proposed earlier: a student who wants to
start a weight reduction group at school, a client recovering from bypass surgery
and experiencing depression, and a returning veteran with TBI. Based on our
literature review, counselors today do not seem to be adequately prepared to
effectively treat these very common situations. Although counseling embraced
a wellness philosophy more than four decades ago and still uses it to distinguish

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itself from other mental health professions, there is still a lack of formal support
from professional counseling organizations and accreditation bodies. This void
has limited market demand for mental health counselors in such healthcare
settings as the Veterans Administration and is responsible for the dearth of
professional health and wellness expertise in counselor trainees. Yet health and
wellness counseling is likely to increase in importance as the population ages,
health problems like diabetes and obesity become more prevalent, and the
nation continues to be preoccupied with fitness. Counselors are not prepared
to operate in this growing market.
Two primary actions are needed to move counseling into the growing
healthcare paradigm: (a) Counselor training programs should either require
a course in Wellness Counseling or infuse such content into the entire curriculum. This recommendation is supported by the consensus definition of
counseling put forth by the 20/20: A Vision for Future Counseling task force
(Kaplan & Gladding, 2011). As part of that effort, wellness competencies need
to be specified. (b) To improve the health and wellness of our clients, mental
health counselors need to embark on more interdisciplinary relationships
with other healthcare professionals and to conceptualize mental health issues
within a biopsychosocial framework (Kaut & Dickinson, 2007). In sum, as
mental health counselors we must take action to build on the professions foundation of wellness and to recognize and adapt to changes so that we are better
prepared for the changing climate of healthcare.
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