Tag Archives: Counselors Audience

Counselors Audience

Record number of military suicides begs questions about the path forward

Heather Rudow February 1, 2013

8410502197_b2223c9814_zDespite recent efforts from the Department of Defense to stem the rise in military suicides, the number of service members who took their own lives last year appears to have topped the number of troops killed in combat.

Despite the Pentagon’s recent efforts to hire more mental health workers, begin a long-term study of mental health for military personnel and expand the reach of mental health services for service members and their families, there were 349 active-duty suicides in 2012 — a record high.

Art Terrazas, grassroots advocacy coordinator for the American Counseling Association, believes if it were easier for licensed professional counselors to join in the Pentagon’s efforts, then the rising military suicide numbers would have a better chance of decreasing.

“The news is deeply saddening and, at the same time, troubling,” Terrazas says. “Any loss of life is tragic, and that tragedy is compounded when someone falls victim to suicide. What is also troubling is that despite the fact that mental health in the military has gained more attention in the past year and more efforts have been made to address mental health care, we continue to fall short of meeting the goal, which is reducing or eliminating suicides among our service members.”

Last year, ACA conducted an aggressive outreach campaign to various media markets to highlight the fact that the Department of Veterans Affairs fell behind in its efforts to recruit and obtain all available mental health clinicians, specifically licensed professional counselors.

ACA’s Public Policy Department believes the DOD has still not done enough to get military personnel the mental health services they need.

“From our point of view, if you are going to do all that you can to meet the mental health care demands of the troops, then that means you are going to utilize all the tools at your disposal,” Terrazas says. “[The DOD] is not doing that. They are sidelining thousands of counselors from working with our military members because of rules that they have created. The DOD is putting up its own barriers when it comes to recruiting every mental health clinician to combat this very serious problem.”

Terrazas says he hears from counselors across the United States almost every day who are being denied work at VA facilities.

“Many of these counselors are veterans themselves,” he continues. “Counselors have not been given the chance to help combat this problem simply because the government hasn’t allowed them to be part of the solution.”

ACA member David Fenell is one of those counselors who has been on both sides of the fence. As a colonel and behavioral sciences officer with the U.S. Army and Army Reserve, he retired in 2009 after 26 years of service, which included tours in Afghanistan and Iraq. Since then, he has counseled soldiers returning from deployments on how to fit back in with their families at home.

When Fenell first heard the news of the suicide numbers, he says he “felt sad that so many of our warriors were so desperate and in such pain. I was sad that they found no options, other than suicide, to relieve that pain and desperation. We try to prepare our soldiers to be resilient and provide them with tools to face adversity, but that training does not seem to have helped those who took their lives.”

Fenell believes the DOD has a lot of helpful programs for military personal in need. “Unfortunately, these programs were either not accessed by the struggling warriors or were not effective if used,” he says. “I know the DOD is currently reassessing its suicide-prevention strategies.”

Fenell points to a Dec. 24 issue of Army Times, which, he says, “reported that about half the 301 service members who committed suicide in 2011 had accessed a mental health provider or received inpatient care before committing suicide. About a third of these had received services within 90 days of their deaths. Over 50 percent of the service members who committed suicide had no known mental health diagnosis. Over 70 percent were drug- and alcohol-free at the time of their death.”

Part of the problem continues to be stigma, Fenell says.

“Service members may seek help but may not fully disclose the depth of their pain because they don’t want to appear weak,” he says. “Also, military mental health care, because of the intense demand for services, can be sporadic. So a client whose depression deepens may not have an appointment scheduled and may be unwilling to call emergency services.”

Lynn Hall, dean of the College of Social Sciences at the University of Phoenix and author of the book Counseling Military Families: What Mental Health Professionals Need to Know, agrees.

“My thoughts go to what are we not doing for these service members and how can life seem so hopeless [for them],” she says. “We talk about moving beyond the concept of the stigma of seeking help, but doesn’t this indeed suggest that we haven’t done enough to decrease this stigma?”

Hall, a member of ACA, says she has found through her research that three conditions are typically present when a suicide occurs:

  • A weapon is available and the individual has been trained to use it.
  • The individual has experience or some level of comfort with death.
  • The individual has a fear of being a burden on others.

With members of the military, Hall says, the first two conditions are present. “Military are trained to use weapons and have weapons available and, at least for those in combat, have experienced death. Therefore, it is only the third condition that perhaps we have not focused on enough in the mental health world.”

The most common characteristics of military life are change and transition, Hall says, and with any change or transition comes grief and loss. The power of accumulated grief over time to lead to high levels of distress is often not recognized, Hall says. “Every person in a military environment must learn how to make healthy transitions, and perhaps everyone going into the military needs to be assessed for prior loss and unfinished grief.”

The relevant questions then become, Hall says, “Does something in the military experience trigger this fear of being a burden on others? Is this what pushes service members over the edge? Being a burden on their families and/or their communities because of their emotional state or even their physical injuries?” If so, Hall says, “might we not focus on this aspect of ‘healing’ for all in the military, or possibly focus more on preventative measures in military training?”

Terrazas believes utilizing counselors is one of the only ways to reduce the number of suicides in the armed forces.

“Federal agencies have made the decision to place barriers that keep counselors from treating service members, military families and veterans,” Terrazas says. “Even though past congresses and presidents have clearly stated that counselors should be part of the effort to treat invisible wounds of war, there seems to be an effort in several agencies to promulgate rules that keep counselors from working [with] the VA and the DOD. Those rules need to be changed so that we can start getting as many mental health clinicians as we can into this fight. It wouldn’t require an act of Congress, it wouldn’t require a lot of hoops to jump through. All it would take is for the administration to [make] some common sense changes so we can get people the help they need. [Counselors] have not been given a chance to help solve the problem.”

Fenell, too, thinks counselors could play a much greater role in the effort to reduce military suicides.

“Licensed professional counselors are trained to establish effective and continuing therapeutic relationships with their military clients,” he says, “and many suicidal service members need a stable, ongoing, supportive relationship to help get through the darkest periods of their depression. Counselors can effectively provide that type of intervention.”

Additionally, Fenell points again to the Army Times issue which states that the most noted causes of military suicide were broken relationships, workplace problems and financial problems. “Licensed professional counselors can be effective in helping in each of these problem areas,” he says.

Hall says she believes that on a local level, “Every single counselor, social worker, psychologist, even physician, who sees a service member must be screening for suicide ideology. This is not something that should happen only when there is a crisis or major loss, but with everyone. We in the mental health world are perhaps not paying close enough attention to the accumulation of grief/loss issues and assume that if someone ‘looks’ healthy because they are capable of functioning, that they are indeed healthy.”

She also questions whether society has the responsibility of raising boys in a less stereotypical way, teaching them that “being a warrior with all its ingrained messages about being dependable, not needing help, being strong, not being weak or invincible is not the ultimate demonstration of being male. The military is, for some young men, the exaggeration of this stereotype, and we may not have enough up-front assessment of our young people to determine the reasons why someone joins.”

It is ACA’s hope that the suicide rate will go down to zero next year. But unfortunately, Terrazas says, there is no indication that will happen.

“The RAND Corporation told us that in 2009, we lost more service members to suicide than we lost in combat in either Iraq or Afghanistan, and 2012’s numbers are higher than they were in 2009,” Terrazas says. “While there has been a lot of work and a lot of resources have been dedicated towards ending this terrible problem, we as a country are still failing and we as a country need to do more. We just hope that both the Department of Defense and the VA will finally listen to recommendations that ACA has made over the past year so that we can get more counselors where they’re needed. And we hope that we all remember this and remind ourselves that this is part of the true cost of war. This is part of the price that we pay when we activate the members of our armed services, and it’s a cost that we should never forget.”

Heather Rudow is a staff writer for Counseling Today. Contact her at hrudow@counseling.org.

Why I am tired of thanking our members

Richard Yep

Richard YepI know it is an unusual headline for a column, but in looking back through past issues of Counseling Today, I was struck by the number of times I have expressed appreciation to so many of you for contacting ACA about volunteering your services after some natural or person-made disaster. I am constantly in awe of your goodness and your willingness to use your skills and expertise to help those affected by tragedy. So, don’t get me wrong. I genuinely appreciate your willingness to help. But I am concerned about the increasing number of times I am compelled to thank you each year.

As I write this, our most recent tragedy is the shooting at Sandy Hook Elementary School in Newtown, Conn., in which 20 schoolchildren and six school staff members were killed. This past July, one of our own ACA members, Alex Teves, was among 12 people killed at a shooting at a movie theater in Aurora, Colo., as he shielded his girlfriend from harm. Fifty-eight others were wounded in that massacre. Look back over the past several years, and all you have to do is mention Columbine, Virginia Tech, 9/11, Oklahoma City or any number of other places to remember the horror of what humans can do to other humans. And I know a good number of you are involved in responding to tragedies and traumatic incidents that occur around the globe as well.

In addition, let’s not forget the violent acts conducted in many urban areas each and every day. Professional counselors working in community agencies, private practices, hospitals, schools and colleges are brought in (or volunteer their time) to help in the aftermath of these occurrences as well.

In the wake of such person-created tragedies, there often follows an outcry for politicians to focus on gun control. However, we are now hearing more people talk about access to mental health services as well. To me, this is a long-overdue demand that should be free of partisan or ideological bickering on the part of our elected officials.

I hope you will chime in on this discussion as well. Why? Because as professional counselors, counselor educators or graduate students preparing to practice, you are the ones who have seen the suffering that is the result of a society with inadequate access to mental health services.

I realize we cannot always know with certainty what makes someone engage in an act as horrific and heart-wrenching as what took place at Sandy Hook Elementary School — an act that caused virtual strangers thousands of miles away to shed tears upon hearing about it. But what we do know is that the work you and your colleagues do really can be instrumental in reducing the probability of even more heinous acts.

Isn’t it about time that we all let our public policymakers know that properly funding mental health services really is an investment that will reap greater benefits to society than they have even imagined? I understand the importance of a balanced budget and spending within our means. But I also realize there are times when investing in services can benefit all of society and will lead to an even more prosperous (and peaceful) world.

As always, I look forward to your comments, questions, and thoughts. Feel free to call me at 800.347.6647 ext. 231 or via email at ryep@counseling.org. You can also follow me on Twitter: @RichYep.

Be well.


It starts and ends with you!

Bradley T. Erford

Bradley-TThis month’s cover story is on bullying, a terrible societal concern among our youths, but also one that still occurs regularly in the adult population. Although some studies indicate that physical bullying is declining among school-age youths, relational aggression and cyberbullying have yet to peak. The humiliation experienced by victims of any kind of bullying is devastating — at any age.

One of the factors often linked to bullying behaviors is the environmental context. People who experience bullying behaviors do not feel safe in their environments. They also feel disempowered to make the behaviors and insults stop. We have made great strides in passing policies and codes of conduct, but we have a long way yet to go.

Unfortunately, bullying is not an act that occurs just between the bully and the victim. Bystanders and witnesses (youths and adults) perpetuate and support this behavior by failing to intervene. The same is true in relational aggression, cyberbullying and even gossiping — all are aimed at destroying the social connections of the victim. Making society a more peaceful and equitable place requires constant vigilance; quick, thoughtful actions; and mutual respect among all people. How we deal with conflict, gossip and the people affected is a reflection of who we are as professionals — and as human beings. We would never treat our clients and students that way; there is no place for physical or relational aggression in the safety of a confidential counseling relationship based on genuineness, respect and empathy.

As a professional community, we are a microcosm of this larger society and have the opportunity to create an environment for respectful, peaceful discussions about issues of importance to express opinions and forge consensus. Often we are successful; sometimes we fail. Some of you are aware of the recent conflicts that have played out on professional Listservs, where counseling professionals have engaged in what I can only describe, in the politest terms, as uncivil discourse. Although I heartily support freedom of speech, the tone of the “discussion” on one Listserv led to dozens of people leaving the Listserv altogether. I imagine many, many more removed themselves without signing off publicly. This incident made me recall that just because we have the freedom to say something doesn’t mean that we have to — or even should. There truly is a difference between a right and a responsibility.

ACA is committed to sustaining the environmental context of respectful discourse that our members expect — one that treasures the richness that comes from diverse thoughts and perspectives aimed at elevating our clients and students through legislative and social justice initiatives. The “soft launch” of ACA’s exceptionally improved website in mid-January is a testament to this mission. It provides cutting-edge professional information, such as the new ACA Practice Briefs, and allows groups of members to connect in safe environments for educational, professional and interpersonal development.

ACA respects and values the diverse beliefs of our members and believes the path to meaningful professional and social change is through engagement, discussion, collaboration and thoughtful, proactive professional and legislative initiatives. This path is the polar opposite of physical, cyber- and relational aggression. Words mean things; behaviors matter. How we treat others and mind our manners are extensions of who we are at our core.

My deepest hope is that from these events, a culture of civility, nurturance and forgiveness will continue to be forged, and that ACA, its divisions, branches and professional partners will continue to represent a place where all members feel welcome and where all voices — not just the most persistent, the loudest and certainly not the rudest — can be heard. We need to model for our students, clients and each other how to resolve conflict productively and create an environment of safety, respect and support. It all starts and stops with each and every one of us.

Evaluating cloud-based practice management systems

Rob Reinhardt


Click here to read part two in this series.

Many of us in private practice have expressed the desire for a paperless office, although this dream has become a possibility only in recent years. Completing all of our work via a laptop or tablet is a panacea that saves time, hassle and, usually, money. One of the major pieces of the paperless office puzzle is the cloud-based practice management system.

Most counselors know that a practice management system handles features such as scheduling, notes, billing and claims filing. Until recently, these packages required “traditional” software, installed on a computer or server. But an explosion of cloud-based solutions has since taken place. In this two-part series, I will provide an overview of these solutions, as well as considerations when evaluating them for use in private practice.

Cloud computing

Cloud computing is the delivery of software or storage over the Internet to a group of end users. Facebook, Dropbox and QuickBooks Online are well-known cloud solutions. These solutions exist on a server and are accessible via any device that can connect to the Internet. A more specific term for practice management solutions delivered via the cloud is “Software as a Solution” (SaaS).

With traditional software, there is typically a significant up-front cost that involves the purchase of both the software and the hardware (computer/server) to run it. Then there is the absorption of the cost of maintenance and support. Typically, these software solutions are accessible only via a local network, and additional users or upgrades to the software normally increase that cost.

With cloud-based solutions, the software is already installed on an Internet server owned by someone else (the vendor). These solutions require only an Internet connection and a web browser for access. This approach allows entry and viewing of data from multiple offices and multiple devices. Typically, little up-front cost is involved; instead, there is a monthly fee.

Although the long-term costs of a cloud solution eventually can approach the costs of a traditional software solution, a couple of factors mitigate this. Costs associated with a cloud solution cover not only maintenance and storage but also ongoing development that includes new features and upgrades.

Now is a great time to find a cloud-based practice management system. Dozens of companies are developing solutions and competing for business. Because this is a new and developing technology, many of these companies are open to user feedback and are developing their systems rapidly. With this new trend, expect regular updates and new features.


One of the first considerations when evaluating a cloud-based system is security. Mental health care professionals are well aware of the importance of complying with the Health Insurance Portability and Accountability Act (HIPAA). The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 clarified rules regarding electronic communication and storage of protected health information (PHI). At this writing, when it comes to software, two core components must be in place for HIPAA compliance:

  • The software and vendor policies and practices must adhere to HIPAA regulations.
  • The clinician and software vendor must enter into a business associate agreement.

The first step is easy and somewhat meaningless. Most vendors marketing this kind of software will report that they are HIPAA compliant. To truly seal the deal, they should be willing to enter into a business associate agreement. This contract is a legal document that clearly states how the vendor is in compliance with HIPAA and what steps it is responsible for taking to ensure continued compliance.

HITECH added new provisions requiring that all electronic PHI be encrypted to be considered secure. The question of whether PHI is secure becomes relevant when considering the new Breach Notification Rule. According to the HITECH Act, a breach is defined as “an impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of the protected health information such that the use or disclosure poses a significant risk of financial, reputational or other harm to the affected individual.”

Should such a breach occur, the covered entity is required to notify all individuals affected by the breach and report the breach to the U.S. Department of Health and Human Services. Further, if the breach affects 500 or more individuals, or if current contact data for 10 or more of those individuals are not accurate, the media must also be alerted. If the covered entity is using qualified encryption techniques, however, it is possible to bypass the Breach Notification Rule. It is important to note that the HITECH law defines very specific qualified encryption techniques, and most of the affordable solutions available do not utilize these techniques. For that reason, it is important that plans for handling a potential breach are addressed within the business associate agreement as well as in a practice’s HIPAA privacy statement.

With electronic applications, HIPAA is complex. Consult with a qualified attorney regarding the implications of using any electronic system for storage and transmission of PHI.


Notes are an integral part of the work of counselors. Maintaining good clinical notes allows a provider to recall information more readily, focus on targeted goals, track progress and fulfill insurance company requirements. Other notes kept may include psychotherapy/process notes, contact notes, appointment cancellation notes, termination notes, assessments and more.

In software solutions, notes are typically attached to a client record, sortable and accessible with a click or two. Compared with locating a specific note in a file folder in a locked filing cabinet, the time savings are obvious. With cloud-based systems, the ability to access these notes from any Internet device is invaluable.

There are many features to consider when evaluating an electronic note-taking solution. In many cases, what must be included in a note is driven by insurance company requirements. There is often some discretion in how notes meet these requirements. However, a well-organized, full-featured notation system makes it easier not to miss anything.

It is important to also consider two key pieces of HIPAA when evaluating a software solution for notes. First, HIPAA specifically requires that psychotherapy or process notes be kept separately from the medical record. Most systems implement this by keeping clinical and process notes in separate fields and by not including the process notes in any printing of the clinical record. To be extra safe, consider not entering process notes into the software at all.

The second facet of HIPAA to consider concerns security. Electronic records containing PHI must be protected from improper alteration or destruction. This means the system must possess safeguards ensuring an unauthorized party cannot make changes or destroy the electronic record. In addition, for the record to be legally admissible, it must be locked and signed in a way that can be authenticated. This means the solution must provide an audit trail noting who signed the note.

HIPAA doesn’t specify how this must take place in an electronic record, so solutions are addressing this requirement in different ways. Consulting with an experienced HIPAA expert or attorney to ensure compliance is recommended.

Among additional features to look for and evaluate regarding notes:

  • Types of notes: These include intake, contact, appointment cancellation, discharge and assessment/evaluation notes.
  • Integrated treatment plans: A good system allows for creation of a treatment plan that is integrated into notes and documentation.
  • Prepopulation: Some systems will allow information to be pulled from previous notes and other client data into a new note.
  • Multiaxial diagnosis: This feature allows users to quickly enter diagnostic codes by using an auto-complete, search or pull-down menu system.
  • Clinical note styles: Some systems allow for multiple note styles, including SOAP (subjective, objective, assessment and plan) and narrative. A select few even allow creation of custom templates.
  • Required fields: It is important to note which fields must be filled out prior to saving. This can be very helpful in ensuring compliance with insurance and agency requirements.
  • Attachments: Having completed a written activity with a client, it is helpful to be able to upload a copy or scan of the activity to the client’s note.


Regarding clients, practitioners need to at least track names and contact information. If filing claims, other data points such as insurance ID, date of birth and referring doctor’s National Provider Identifier number become important. Practitioners who accept insurance may benefit from additional functionality such as the ability to track copays, deductibles and the number of approved sessions remaining. Any client information tracked beyond that point is a personal or business preference.

Different solutions may store specific client data in separate parts of their systems. For example, one solution might track the medications a client is taking directly in the client record. Other solutions require entering such information into an intake note. When evaluating a cloud-based solution, it is important to consider what data to track as well as how it should be organized.

Some additional features to look for and evaluate regarding clients:

  • Contacts: Counselors will need to track contact information for the client and for at least one emergency contact for the client. Ideally, practice management systems should be able to track alternative phone numbers and email addresses, and indicate if a client allows messages to be left at each contact point. The ability to add several related contacts for the client can be important, especially when working with children and/or blended families.
  • Integration: Providers should be able to quickly access data related to a client. Within a click or two, or even directly on the client page, a user should be able to view an individual client’s appointments, notes, insurance claims and billing.
  • Insurance tracking: Counselors who accept insurance need to be able to track information required to file a claim, including insurance identification
  • numbers, preauthorization codes and referring doctors.
  • Billing information: It is important to be able to quickly access a client’s fee and balance owed.
  • Attachments: In the quest to go paperless, the ability to upload intake forms, assessments and copies or images of insurance cards is essential.
  • Forms: Some solutions offer web-based forms that the counselor and/or client can complete. A select few solutions even allow creation of custom forms and incorporate electronic signatures, eliminating the need for paper forms altogether.
  • Custom fields: This feature allows the naming of fields and the tracking of information that doesn’t come standard with the product.
  • Search/reports: Being able to search and run reports on multiple criteria (name, date of birth, referral source, insurance company and so on) allows for more efficient use of the database.


Unless a counselor is gifted with perfect memory, a tool for keeping track of appointments is necessary. An appointment book still offers two distinct advantages over a traditional software solution: 1) counselors can retain possession of it at all times (portability) and 2) they do not need to be at the computer with calendar software running (access). The combination of cloud computing and mobile technology offers these same conveniences via laptop, tablet or smartphone — and throws in data backup to boot. Now, opening an appointment book can be as easy as powering on a mobile device.

As is the case with notes, appointment scheduling is a core feature of all cloud-based practice management systems on the market. A scheduling module should allow users to create appointments that include a date, time and client name or initials. Most systems link client data to appointments, allow creation of other types of appointments (meetings, lunches and so on) and display appointments both in daily and weekly formats. Other features are less universal, such as the ability to create recurring appointments, send appointment reminders to clients and give clients the ability to see their appointment schedules online.

Some additional features to look for and evaluate regarding scheduling:

  • Flexible views: This includes daily, weekly and monthly views of the calendar.
  • Client integration: It is important to be able to set an appointment with one click while viewing the client’s data screen. Similarly, it is nice to be able to access client data from his or her appointment on the calendar.
  • Additional integration: It saves time when appointments are also integrated with billing and electronic claims modules.
  • Recurring appointments: In counseling, recurring appointments are the norm, making the ability to create appointments that automatically repeat on a daily, weekly, biweekly or monthly basis especially valuable.
  • Customize availability: This feature allows counselors to enter the hours they are available for appointments, which cuts down on scheduling errors.
  • Client reminders: Appointment reminders decrease no-show and cancellation rates. Having a system that automatically sends these reminders via email, text and/or phone is a boon.
  • Track cancellations: The ability to track missed and canceled sessions is important.
  • Exportable: Exporting appointments to another calendar (typically in iCal format) allows users to integrate with their personal calendars, for example. Be sure to consider the privacy concerns that follow, however.
  • Privacy: Some systems provide preference settings for how to display client information on the calendar: full name, partial name or initials.
  • Client accessible: Some systems allow clients to log in and view their upcoming appointments.

In the second half of this two-part series, I will cover billing, electronic claim filing, client portal and miscellaneous features, and list the current products on the market.

This article and the article to follow in March are distilled from a 12-part series that the author originally published at tameyourpractice.com/blog

HIPAA and mental health professionals

Most counselors are well-acquainted with the Health Insurance Portability and Accountability Act (HIPAA) regulations regarding privacy. Many professionals, however, have only a basic knowledge of the security facets of HIPAA. With the recent release of the HIPAA Final Rule, it has become even more important that counselors are aware of their responsibilities when it comes to security electronic PHI (protected health information). In an upcoming article for his new Counseling Today column, Rob Reinhardt will be exploring where counselors are now, where they need to be and how they can get there. Please help him tackle the first part of his article by completing a brief survey about mental health professionals and HIPAA at https://www.surveymonkey.com/s/MJPHTCF.

Rob Reinhardt, a licensed professional counselor and ACA member, is a private practice and business consultant. Before becoming a professional counselor, he worked as a software developer and director of information technology. Contact him at rob@tameyourpractice.com.

Letters to the editor: ct@counseling.org



The paradox of empathy: When empathy hurts

By Eric W. Cowan, Jack Presbury and Lennis G. Echterling

brickWe normally think of empathy in counseling as a benevolent act in which the insightful counselor deeply understands the grateful client. Carl Rogers considered this empathic connection the centerpiece of a successful counseling relationship. He offered the following metaphor of the imprisoned client being emotionally liberated by the counselor:

One thing I have come to look upon as almost universal is that when a person realizes he has been deeply heard, there is a moistness in his eyes. I think in some real sense he is weeping for joy. It is as though he were saying, “Thank God, somebody heard me. Someone knows what it’s like to be me.” In such moments I have had the fantasy of a prisoner in a dungeon, tapping out day after day a Morse code message, “Does anybody hear me?” And finally one day he hears some faint tappings which spell out “Yes.” By that one simple response he is released from his loneliness, he has become a human being again.

Such images of empathic connection have become common wisdom in the counseling profession. We strive for this empathic understanding of our clients to establish a warm and trusting relationship. But is it possible that instead of the client welcoming this level of closeness and understanding, he or she might regard the counselor’s ability to “see the whole person” as an intrusion? Instead of wishing to be fully known by the counselor, might the client regard empathic understanding as a penetration into protected areas of the self, stimulating feelings of exposure, anxiety and shame? Therapeutic empathy creates a paradox. The client wishes to be seen, understood and validated but does not necessarily want be completely known, even to himself or herself, because such deep empathy evokes the client’s deepest wounds. In such cases, empathy hurts!

Taking evasive action

The idea that empathy can be hurtful is counterintuitive for most of us. After all, we assume that emotional attunement, sincere regard and understanding of the client’s sufferings are qualities that enhance the client’s ability to become more integrated. We strive to help the client contact and reintegrate those aspects of self that have become lost, cut off or disowned.

But this is where it gets tricky. Those cut off pieces, whether they are certain emotions, ideas, potentialities or ways of being, are sectioned off for a good reason. The reason is because important others in the client’s life did not offer the validating attunement necessary for those pieces to emerge and flourish. In other words, these are the aspects of the client’s being that were never affirmed as legitimate, and the emergence of these potentialities is associated with interpersonal pain, disappointment, rejection and shame.

The client’s increasing contact with “forbidden” thoughts and feelings through the counselor’s empathic efforts can also evoke an anxious sense of vulnerability. The counselor is becoming important to the client as a new attachment figure, and the client fears that the counselor will in some way reject, punish or abandon the client as others have done in the past. Some clients may even fear that the expression of their prohibited and “dangerous” affects or thoughts will injure the counselor. Caught between his or her longing for validation and the fear of rejection or interpersonal injury, the client sometimes takes evasive measures before these new traumas can happen. The counselor is naturally confused when, in response to the counselor’s sensitive attunement, the client suddenly begins creating conflict, criticizing the counseling process as unproductive, assigning to the counselor feelings and thoughts that confirm the client’s expectations of rejection, or refusing to allow the counselor to become an important attachment figure. When these dynamics happen, the counselor may conclude that the client is being “resistant.”

The idea is not new. Freud thought that such clients wished to avoid unconscious conflicts or impulses and became resistant to intervention due to this material bubbling up from within. But Freud got it only half right. Clients wish to avoid not only intrapersonal anxiety and conflict but also any reenactment in the relationship with the counselor of interpersonal traumas and developmental disappointments. When counselors recognize that empathy hurts, they pay attention not only to how the client’s conflicts make sense in terms of past disappointments and injuries, but also to how these conflicts continue to play out both in the therapeutic relationship and, more important, throughout the client’s life. To effectively work with the emergence of the client’s painful conflicts and the reenactment of these conflicts with the counselor requires that we see these disruptions as opportunities to identify and reclaim lost parts of the self and, ultimately, as therapeutic consequences of deep empathy.

Every person “grows a self” in countless encounters with important others, developing self-awareness and acquiring a language for integrated emotions, thoughts and other aspects of internal life. A lack of sufficient and accurate empathy early in life means that a person not only is disconnected from others but also, over time, becomes disconnected from his or her own internal experiences, which can emerge later only in conflicted and ambivalent expressions. Another consequence of insufficient mirroring is that the person sees unvalidated aspects of self as potentially harmful to important attachment relationships. Any offending emotions, thoughts and self-expressions that threaten primary attachments must be cut off, repressed or otherwise disowned to keep these relationships stable. The personality forms around the obstruction in the same way a tree trunk grows and scars around the strands of a barbwire fence, incorporating what would otherwise sever it. The reemergence of the unvalidated and repudiated potentialities in response to the counselor’s empathy is often attended by a profound sense of shame.

When someone experiences shame, the person is evaluating his or her own behaviors in terms of some external standard, such as the reaction of an important attachment figure. In shame, a person has a heightened sense of self-consciousness. Humiliated, the person feels a loss of control that brings about the desire to hide because he or she feels unworthy. Such evaluations are often first conveyed by others and then become internalized as aspects of the self. Expressions of disgust or contempt on the face of another person give rise to feelings of shame. Another’s withdrawal of love also creates a sense of failure, worthlessness and humiliation.

Some theorists have suggested that shame brings about depression due to the lowering of self-esteem as a result of failure to meet one’s own narcissistic aspirations. Narcissistic aspirations are simply the desire to feel special and to be successful in attaining one’s goals. We all have such aspirations, and when we believe that our failure to realize these ambitions is because of our own basic flaws, we feel ashamed. The deep-down injury that accompanies shame is the narcissistic wound that sometimes festers for years. It is the belief that something is fundamentally wrong with us that may not be remediable. Even more disturbing is the fear that the counselor might view with revulsion these profoundly flawed parts of the client’s self. When the client “feels felt” by the counselor and believes that the counselor fully understands his or her implicit and guarded world, then empathy can be a threat.

Case example

One of the authors of this article worked with a female client who was raised in a fundamentalist religious environment. Her imposing uncle, who was her main caregiver, squelched any impulse that he did not consider to be “Christian.” Anger, pride, assertiveness and sexual feelings were all treated as damning defects in a little girl. Any expression of these legitimate self-experiences caused disruption in the client’s primary relationships. She learned early on to dissociate or repress the shameful inner thoughts and feelings.

By the time she came to counseling, this client had developed an obsessive personality style that greatly constricted her ability to form intimate relationships with others. The disowning of her shameful sexual impulses caused the client to persistently assign her own thoughts and fantasies to a succession of male authority figures whose conventional expressions of regard she interpreted as ploys to seduce her. Not surprisingly, as the counselor became an important attachment figure, the counselor’s expressions of positive regard were similarly interpreted.

Above all, the client carried an unmet longing to feel valued and special to someone. Paradoxically, she experienced her longing for acceptance as a threat, and anytime she felt prized by the counselor, she felt compelled to withdraw. Her shame, associated with all denied aspects of herself, would rise to a level of urgency, and she felt the pain of exposure. “It’s not that you don’t understand,” she remarked in one emotionally charged session. “It’s that you understand too much!” The emergence and reclamation of her legitimate and natural emotions in counseling was, she said, “an act of disobedience. … It feels like killing off people who are already dead but who live in my head.”

Three types of empathy

As counselors, we are committed to helping others, and we often shy away from causing pain. As a result, many counselors confuse empathy with being warm and sympathetic. Thus, a number of counselors who hope to be empathic wind up simply being nice instead. But clients do not change simply because someone has been relentlessly nice to them. Rather, true empathy involves not only emotional resonance but also “getting” the client from within the frames of reference that organize his or her subjective life.

As Simon Baron-Cohen observed in his summary of three types of empathy, a sympathetic impulse is one component of empathy and involves feeling an emotion in response to someone else’s distress that moves us to want to alleviate another’s suffering. This is a natural human response and part of our normal reaction to clients’ suffering, but it cannot be allowed to be the primary guide to our interventions as counselors.

A second component of empathy is the affective component, which involves feeling an emotional attunement that Irvin Yalom called “looking out the client’s window.” It is this affective resonance that allows clients to go deeply into their pain with the participation of the counselor as a sensitive companion and compassionate guide. The counselor must not become either overactivated or underactivated by the client’s distress because then the client will disengage and reenact past disappointments. The counselor must empathically be in tune with what Daniel Siegel called the client’s “window of tolerance.” When a counselor is not sufficiently responsive, clients conclude that the counselor does not care. More commonly, when the counselor loses the empathic stance and overidentifies with the client’s pain, the client concludes that the expression of certain affects or sectioned-off parts of self has the power to injure or damage the caregiver. The counselor must help to hold the client’s pain without succumbing to the client’s grief.

The third, or cognitive, component of empathy allows counselors to understand, validate and illuminate the client’s inner world of meanings. This “perspective taking” allows the counselor to use accumulated knowledge of how the client is likely to respond to certain empathic interpretations and interventions. The art comes in the balance of challenge and support.

All of these levels of empathic connection give reassurance to clients that the counselor understands and accepts them. However, if such deep understanding makes visible the aspects of the client’s self that have been partitioned or disowned due to a lack of validating attunement from important others, the client may feel exposed, and the experience of being “found out” might emerge instead.

Practical strategies

Realizing that empathy sometimes hurts, what can counselors do when their empathy seems to be getting in the way of progress? This is where the combination of empathy as an investigating attitude and affective attunement to the present relationship really comes into play.

First, counselors need to recognize and give voice to the sometimes subtle disruptions in the interpersonal process between counselor and client. Shining a light on “what is happening” when the counselor senses such a disturbance or shift toward disengagement invites the client to express the conflicted thoughts and emotions about being so thoroughly “seen.” The idea is that the therapeutic conversation must shift from whatever issue the client was discussing to a focus on the immediate experience of engaging with the counselor as conflicted and shame-eliciting material emerges. Most often, the client will need considerable encouragement to do this because it is the expression of this material with other important attachment figures that previously caused interpersonal disruption and trauma.

We also recognize that the client might not be the only one in the relationship who is tempted to avoid such participation. This strategy is an overture for a deeper, more authentic encounter in the here and now that may also thrust the counselor out of his or her comfort zone into full engagement and immediacy with the client. “How are you experiencing me right now?” is more difficult for the counselor to ask than, “How was it for you when you were experiencing your (father, roommate, boyfriend, wife) back then?”

The point of this approach is that the counselor invites the client to explore the interpersonal consequences, in the current relationship, of expressing formerly forbidden aspects of self. This strategy involves following up this invitation with process comments such as:

  • “You said before that I really seem to understand you but that it scares you. What might I think of you if you allow me to see this part of you that you have kept hidden?”
  • “It seems just then as if you needed to shy away when you felt I really understood you, as if that could be dangerous.”
  • “Your giving words to that part of yourself seemed to make you feel the need to retreat, and you suddenly wondered why I would care.”
  • “I wonder what you saw or heard in me just then that suddenly meant to you that I disapproved of you.”

These are just a few examples of highly empathic process comments that bring the client’s subjective inner conflicts and resultant “resistance” to light and into the ongoing intersubjective relationship where they can be addressed in the present, not merely as artifacts of past interpersonal disappointments. Notice that in the last comment, the counselor does not challenge the client’s sense that the counselor disapproves but instead wonders how the counselor’s words or actions were interpreted by the client and how they signaled to the client that danger was imminent. In all of these exchanges, the emphasis is not directly on solving the client’s expressed problem but rather on illuminating the processes by which the client’s inner world becomes structuralized in the world of interpersonal participation. These practical strategies transform the pain caused by empathy into an opportunity for therapeutic growth.

Attunement to subtle changes in the therapeutic encounter allows us to sense when our clients are feeling too exposed by empathic responses — when they are ashamed of being known too well. The empathic counselor invites the client to realize aspects of self that were dissociated and denied as a result of conditions of worth. It is a sensitive process for the client to allow aspects of self into awareness that formerly were thought to be defective or dangerous. When this finally happens, the client can say, as Rogers stated, “Thank God, somebody heard me. Someone knows what it’s like to be me.” Furthermore, the client will be able to say, “And I am, in spite of my faults, prized by my counselor and owned by myself.”



Eric W. Cowan is a professor in the Department of Graduate Psychology and Counseling at James Madison University (JMU). He is the past director of Counseling and Psychological Services, JMU’s outpatient clinic, and is the author of Ariadne’s Thread: Case Studies in the Therapeutic Relationship.

Jack Presbury is a licensed professional counselor and professor in the Department of Graduate Psychology and Counseling at JMU. He is the author of Mechanizing Minds and Humanizing Machines.

Lennis G. Echterling is a professor and coordinator of the counseling program in the Department of Graduate Psychology and Counseling at JMU. He is the lead author of Thriving!: A Manual for Students in the Helping Professions.


Correspondence regarding this article may be sent to cowanwe@jmu.edu.

Letters to the editor: ct@counseling.org