Monthly Archives: November 2012

Sandy’s aftermath: counselors weigh in on how to help

Heather Rudow November 4, 2012

As the East Coast recovers from Hurricane Sandy, a historic “superstorm” that claimed more than 120 lives and left an unthinkable path of destruction in its wake, Counseling Today reached out to a few American Counseling Association members living in affected areas. We asked them to share their thoughts on how counselors can be of help in both the immediate aftermath of Sandy and also in the long term. First up to share her thoughts is Deb Del Vecchio-Scully, executive director of the Connecticut Counseling Association.

Her office may not have power, but Deb Del Vecchio-Scully, a Hamden, Conn., resident and licensed professional counselor, admits that the hit from last year’s Hurricane Irene was much more damaging than that of Sandy — but, of course, she says, that won’t be true for everyone.

“I think that depending on the impact, you will see varying spectrums on the trauma scale,” Del Vecchio-Scully says. “My house is OK, but 20 minutes south of where I live at the shoreline, homes were devastated. These are people who don’t have homes to go back to, who are living in shelters. This is at the very worst end of the spectrum.”

For counselors residing in areas affected by Hurricane Sandy, Del Vecchio-Scully says it is important to have adequate disaster and trauma-informed training in order to provide professional help in the immediate aftermath. However, even those who don’t have that training will still be able to help in some capacity.

“There are many ways to help out that may not involve traditional roles of counselors,” she says. “There are plenty of opportunities to volunteer at shelters, disaster sites, community centers and churches. You can just go and play games with the kids. Something as simple as giving a kid paper and markers to draw is helpful because … the way the brain processes trauma is not verbal. It’s up to us to give them a way to tell their story, art-making is a great tool to do so.”

Over the long term in Sandy’s aftermath, Del Vecchio-Scully says counselors can expect to see people dealing with issues such as anxiety-spectrum disorders, post-traumatic stress disorder and feelings of grief and loss.

“In the immediate short term,” she says, “you’re going to see people suffering from shock, a sense of surrealness about what’s happening, a denial about the reality of what’s happening [and] a much higher level of stress because of food, personal needs [and] work-related demands. The stress level is much, much higher [than usual]. It continues to stay that way over time because there’s no quick answer to these problems. If your home is destroyed, there is no easy way to fix that.”

Additional stressors, Del Vecchio-Scully says, include the financial impact of the storm, which, she says, will be “pretty significant,” and any losses people endured as a result of Sandy.

A loss of a loved one can very definitely include a pet, Del Vecchio-Scully says. “For many, their pets are considered members of their family and thus, such a loss would be difficult [even] in a less stressful time,” she says.

In many ways, Del Vecchio-Scully says, a counselor’s role after a natural disaster such as Sandy is no different than in any other situation, although the focus is different.

“Disaster mental health focuses on normal people who are responding to an abnormal event and avoids pathologizing reactions,” she notes.

Del Vecchio-Scully says counselors act as case managers immediately following a disaster.

“Focus on connecting people to the resources that they need, things that maybe available through the government, such as grants and housing,” she says. “Also, in some cases, even though people are warned to have enough medication, they may not have gotten any. The practical needs need to be met. You have to establish that internal sense of safety regardless of what’s happening around them.”

Del Vecchio-Scully recommends that counselors keep in mind the four phases of disaster mental health that those impacted by the storm may go through in order to best help them:

  •  Phase 1. Impact Phase: This phase occurs within the first few days of the event, and Del Vecchio-Scully says the role of the counselor is to provide psychological first aid for the natural disaster victims. “People are stuck in their stress reactions,” she says, “and the role of a mental health provider is to help ensure their basic needs are met.”
  • Phase 2. Rescue Phase: “This is when people are either able to cope or become emotionally exhausted,” explains Del Vecchio-Scully, and this phase occurs within the first week of the event.  This is the time for counselors to do needs assessments with their clients. She stresses the importance of being mindful of previous trauma histories. “For people in the tri-state area [New York, New Jersey and Connecticut] who experienced the 9/11 attack,” Del Vecchio-Scully notes, “they are more vulnerable and are much more likely to be re-traumatized.” Regardless of past experience, it is important to focus on normalizing the here-and-now experience and foster resiliency during this time.
  • Phase 3. Recovery Phase: Occurring during the first month after the event, Del Vecchio-Scully says it is normal for people impacted by the event to feel grief and loss during this time, experience intrusive thoughts of the event or be reappraising or reevaluating their lives. The role of the counselor, she says, is to be “very aware, watching, listening and noticing the symptoms, monitoring to see if there is any ongoing stress or threats [to their mental or physical health].” Additionally, Del Vecchio-Scully says to make sure clients are getting their needs met both emotionally and practically, whether it is by ensuring they are receiving entitlements or clean clothes. “Responsiveness and sensitivity are the most important traits [for a counselor] to have,” she says.
  • Phase 4. Returning to Life: Del Vecchio-Scully says to think of this fourth phase as a “continuum,” as it can begin occurring within two weeks after the event and last for years afterward. Evaluate where a client is on the continuum: extreme — losing their house, job or a loved one — or less extreme. “This is where you see people not coping when they should be coping as well as one would hope.” Del Vecchio-Scully says. It is also the point for counselors to start looking at treatment options, whether it be individual, family, group therapy, hospitalization or medication, for as long as it takes to help the individual to cope. “I see a lot of people in my practice who are still impacted by 9/11,” she says. “As much as we try to put time frames on it, people heal when they heal.”

While Del Vecchio-Scully says it’s important to help those affected by disasters learn to cope on their own, she says that offering empathy and sensitivity is also key.

I think the most important thing is no one can determine the impact of another thing on another individual,” Del Vecchio-Scully says. “Whatever their experience is, is their experience. It is that non-judgmental, compassionate presence that we come back to again and again.”

Read parts twothree and four in this series.

Heather Rudow is a staff writer for Counseling Today. Contact her at


Counselor, Educator, Advocate: Counselor starts school club to ‘Pay it forward’

Jessica Eagle November 3, 2012

This is the second in a series of school counselor advocacy stories that will run online as a counterpart to the school advocacy stories running in Counseling Today’s Counselor, Educator, Advocate column. To read the first post in this series, click here.

Greg Kirkham, a school counselor at Zionsville Community High School, had the unique experience of teaming up with his son Josh, a student at the school, to start a club promoting positive, healthy choices.

The club, called Eagles Making Positive Choices, is for students who make a pledge to be alcohol- and drug-free. The group’s motto is “Pay it forward,” which reflects the group’s volunteer spirit within the community and at school activities. During the 2011-12 school year, there were 110 students in the group. Volunteer events included work with Boone Co. Habitat for Humanity, the Special Olympics, area nursing homes, Zionsville Education Foundation and Zionsville Parks Department, as well as tutoring students, guiding new students, raking leaves and shoveling snow for the elderly, and other good deeds within the community.

As a professional school counselor who is constantly working to improve school climate and to create opportunities for students to practice being engaged citizens, Kirkham sees the opportunity of overseeing this Positive Choices group as a natural, student advocate role. Working side by side with the students as a community volunteer has allowed Kirkham to develop personal relationships with students that result in positive, productive interactions during the school day as well.


ACA members expand cultural competencies on People to People trip to China

Heather Rudow November 2, 2012

(Photo by Bill Fenson)

An American Counseling Association-sponsored People to People Citizen Ambassador Program to China gave 17 counselors, counselors and teachers the opportunity to expand their worldview and learn about mental health in a country with a culture different from their own.

The trip allowed delegates — most of whom are ACA members — to collaborate with Chinese students, counselors and workers on topics relating to the counseling profession and to experience cultural activities around the country.

During the program, which was held Aug. 13-25, delegates learned about Chinese culture in unique ways: from exploring local neighborhoods to visiting two of the country’s top universities to observing Chinese counselors in their element. The delegates learned about mental health issues affecting Chinese students, children and adults, about career options for Chinese workers and about what the country’s environment is like for counselors. Attendees had the chance to visit and listen to presentations at places such as the Jinghui Soul Education and Counseling Center, the Career Center at Tsinghua University and the Jie Su Tenzin Orphanage.

People to People began in 1956 when it was founded by President Dwight D. Eisenhower. ACA has previously partnered with the organization to send counseling delegations to countries such as Russia, Rwanda, South Africa, China, Tibet, India and Brazil. While this trip was sponsored by ACA, all travel expenses were paid by People to People and the delegates.

ACA member Tammy Hurst’s first experience with People to People was in 2011, when she went on an ACA-sponsored trip to Brazil. The trip focused on multicultural counseling and was a positive experience, she says.

The August People to People trip to China was Hurst’s first trip to Asia, she says. “I had wanted to visit there for a very long time but never knew how it would work out. When the trip was announced as a multicultural counseling delegation, I knew I had to go.”

Hurst says getting to know the Chinese people she met was one of her favorite parts of the trip, helping her to expand her cultural competencies as a counselor and an American.

“My ideas of what China would be like stemmed back to my childhood when I was told that it was a communist country and was made to believe that it was a cold, gray place with busy and unfriendly people,” she says.

But these notions were quickly challenged the more she encountered the country’s people and culture.

“Today, I am so thankful that I know better,” Hurst says. “I am quite honestly overwhelmed at the amazing hospitality and warmth shown to myself and the entire delegation by every Chinese person we met. The trip reinforced my belief that we should not rely on what we hear in the news, on the radio or even often times from our own families. We must be brave and open to explore the world around us. We must see and touch for ourselves and then form our opinions about our fellow humans. I am forever changed by their sense of loyalty, their passion for life, their seriousness about life, their drive and their wonderful peaceful nature.”

Though ACA member Bill Fenson says visiting Asia for the first time on this trip crossed more things off his bucket list than he can count, he, too, admits to having some preconceptions about what the culture would be like.

“I knew as a tall, large, Caucasian male that I would stand out in the crowds,” he says. “I had only traveled one place before that it was so evident that I was a tourist.”

However, Fenson says, he was greeted warmly wherever the delegates went. “Pleasingly, I wasn’t shocked or embarrassed by the stares or photos,” he says. They were very compassionate, asked for photos and [are] ultimately not so different [from Americans].”

The experience with People to People made Fenson realize how important it is for counselors to travel abroad.

“We get the privilege of representing the United States and sharing the knowledge that we have gleaned from our experience with others,” he says. “I can only think this was a shared learning experience and that we now understand them more than we could from reference books or articles. The experience of a communist country with friendly, idea-sharing and cheerful professionals was not expected.”

Hurst, too, says she believes that one of the best ways to develop cultural competencies is to actually experience other cultures firsthand.

“I feel that a counselor can read all of the books, stories, magazines [and] journals they want about any certain culture out there and they would still know very little,” she says. “Counselors tend to be very intuitive and sensitive people, [but] they need to actually get hands-on experience with the populations they serve. There is no better way to try and relate to our clients than to know something experientially about their culture, language and beliefs. Books would like you to believe that a people are all the same. It is so very important for counselors to realize and experience the fact that all people from a certain nation or culture are all not the same, just as we Americans are very different from each other. When asked how to best serve Chinese American clients in the States, one wonderful counseling professional said to our group, ‘Just remember that we are people, too.’”

Jane Goodman, a past president of ACA, led this year’s group, as she also did for the 2009 delegation to China. She went to the country for her first time with People to People in 1985. Goodman says the experience on this trip was “fascinating, enlightening, fun, sometimes challenging. As we met with people who do what we do, in a country that is so different from ours in so many ways, we were consistently amazed that they are so similar in their challenges and approaches.”

One thing Goodman noticed on this year’s trip is how rapidly the mental health landscape is evolving in China.

“Most of the places we visited had only been in operation 10 years or fewer,” she says, “but [there] are sophisticated counselors with knowledge of the same theories and approaches as Americans and the wisdom to apply them in their own cultural context. [On] my 1985 trip, things were very different and counseling didn’t really exist.”

Although this wasn’t her first time, Goodman says she still managed to learn new things, even as a group leader.

“I find that not only do I learn new things,” she says, “but I ask new questions. For example, on this trip, because the U.S. ‘falling behind’ educationally has been in the news so much, I pondered how one can motivate students without terrifying them and creating as much anxiety as Chinese students have.”

After experiencing China through this unique lens, Fenson is ready to take another type of adventure.

“As a direct result of this trip,” he says, “I am currently seeking an international position based outside the United States to actually work in unfamiliar geographic areas and become an open resource to familiar and unfamiliar venues.”

Fenson says he is grateful for such a positive and rewarding experience.

Goodman adds that the experience has also renewed her faith in the counseling experience.

“I have a renewed respect for the impact of counseling on people’s lives, its power and its universality,” she says. “I am again reminded of the strength in a group, as 17 people who did not know each other bonded and shared both great moments and sometimes the need to help each other with challenges.”

For more information about People to People’s Citizen Ambassador Programs, click here.

Heather Rudow is a staff writer for Counseling Today. Contact her at

Eyes wide open

Lynne Shallcross November 1, 2012

Melancholy piano music plays in the background as people flash back to times in their lives when they felt happiness. Returning to the present, we see individuals in obvious emotional pain. A voice asks, “When you’re depressed, where do you want to go? Nowhere. Who do you feel like seeing? No one. Depression hurts in so many ways.”

If you watch TV, you’ve no doubt seen this commercial advertising one of the growing number of antidepressants now on the market. Regardless of how you feel about these medications, statistics suggest the message from that commercial — that depression can be debilitating and rob people of their sense of joy — likely resonates with millions of viewers. In fact, the World Health Organization calls depression “common,” affecting about 121 million people across the globe. According to the Centers for Disease Control and Prevention, nearly 1 in 10 U.S. adults reports symptoms of depression.

American Counseling Association member Katherine Walker has a private practice in Wake Forest, N.C., and one of her counseling specialties is treating depression. She says clients dealing with depression often feel stuck or overwhelmed with some aspect of
their lives.

“Some may be experiencing a significant loss such as loss of a job, loss of previous status or esteem, loss of a significant relationship or the death of a loved one. Others may be dealing with some internal conflict — body image, poor self-esteem, etc. — or experiencing conflict in their relationships with others. We know that depression can either be situational or recurrent, lasting hours, days, weeks, months or even years. It can affect them not just mentally and emotionally but also physically, relationally, vocationally and spiritually. Regardless, these clients often describe their depression on a continuum ranging from feeling blue or ‘in a funk’ to experiencing overwhelming emptiness and despair. They feel helpless, hopeless and victims to whatever they are experiencing,” says Walker, who has also worked as a counselor in an outpatient physical rehabilitation setting and as part of an employee assistance program.

Having trouble concentrating, feeling a lack of desire to do anything and feeling a general sense of malaise are also common among those experiencing depression, says Gary Gintner, an associate professor and program leader of counselor education at Louisiana State University and a past president of the American Mental Health Counselors Association, a division of ACA.

We all hit bumps in the road of life. The question is why these bumps land some people “in the ditch,” while others seem to power through without losing course. Walker points to genetics and the individual’s environment as two major factors that determine the likelihood of depression. Those individuals with a family history of depression — especially a biological parent who has struggled with depression — are more likely to experience depression at some point in their own lives, she says. Moving beyond genetics, a history of abuse, stressful life events, loss of previous status or role, conflict in interpersonal relationships and loss of loved ones can also increase a person’s likelihood of living with depression, Walker says. Certain medications such as beta-blockers and medical problems such as cancer can also increase depression risk, she adds.

Says Richard Hazler, a professor of counselor education at Penn State University and a member of ACA, “No different than most disorders, genetics appear to make some people more likely to suffer from depression and some less, but it is the environment that tends to trigger reactions [and] make the depression less severe or more severe.”

Certain clients who seek counseling will present with clear symptoms and be “painfully in touch with their depression,” Walker says, making it relatively easy for the counselor to determine what is going on. “For others,” she says, “it might be more insidious, especially for individuals who may be unaware and not in touch with themselves, are in denial of their symptoms or tend to be more stoic in nature and put up a front for fear of being perceived as being weak or a failure.”

In searching for clues of depression in clients, Walker says counselors should pay close attention to the following symptoms:

  • Reported or observed signs of sadness, including poor eye contact, strain in the facial muscles around the eyes and mouth, slowed movement and speech, slumped posture, crying in session and reported bouts of tearfulness
  • Wanting to withdraw and hide from responsibilities and relationships
  •  Feeling either overwhelmed or underwhelmed in life roles
  • Experiencing a loss of appetite or engaging in emotional eating
  • Experiencing decreased sex drive
  • Having sleepless nights or sleeping excessively
  • Feeling helpless and hopeless
  • Feeling fatigued and achy
  • Having trouble remembering, concentrating or making decisions
  • Feeling a loss of pleasure for previously enjoyable or meaningful activities and apathy for things once important to them
  • Feeling worthless
  • Feeling a general lack of direction, meaning, purpose or motivation

Asking clients whether or how their habits have changed can also provide possible indicators of depression, Hazler says. For instance, if clients say their sleeping patterns have changed recently, their eating habits have changed recently and their interactions with friends and family have changed recently, those might be warning signs of depression, he says.

Different paths to treatment

Gintner says three approaches are empirically supported for treating depression across the general population: behavior therapy, cognitive therapy and interpersonal therapy. Behavior therapy is often a good initial treatment, Gintner says, because it is fairly straightforward and encourages clients to make changes in their activities or lifestyle. Cognitive therapy is beneficial when the main component of a client’s depression is connected to his or her thoughts, he says. Interpersonal therapy fits well with clients experiencing a significant number of interpersonal problems related to their depression, Gintner says.

From his experience, Hazler believes a counselor’s best route is to follow his or her own preferred clinical approach. “If you are a good counselor and you have a solid theoretical viewpoint and it works consistently, that’s what you should be doing,” Hazler says. “All the research shows that the core relationship and counseling skills have the greatest impact on client outcomes, and those skills are used across all major counseling theories. We have counseling theories — plural — because no one theory has proven to be perfect or uniformly better than others. The combination that seems most important is a counselor with basic skills and a sound belief in and ability to implement a theory that will do the best job.”

Walker deems her theoretical orientation a bit “eclectic,” combining rational emotive behavior therapy and solution-focused therapy with mindfulness and awareness, and that is the treatment path she follows with clients struggling with depression as well. Walker says her goal with these clients is to help them live more authentically rather than always striving to be what others expect them to be.

“I work with clients to help them uncover their true potential and to [live] life more assertively, meaningfully and adaptively, and to do so mindfully with awareness,” Walker says. “I try to help them make sense and find meaning out of what may feel [like] insurmountable circumstances or traumatic events they have had to endure. While we can’t change difficult situations of the past, we can work to better understand and resolve challenges in our life by realizing our true potential to be our own change agent. By applying complementary therapy approaches and techniques, I work with clients to unearth long-standing behavior patterns or negative perceptions that may be holding them back from experiencing a more fulfilling and meaningful life. I believe as counselors, we need to help our clients identify areas where they feel stuck, establish reasonable and attainable goals, break [from] feeling victimized by their circumstances, and feel more empowered and be more adaptive and resilient in their lives.”

In certain cases, these counselors say, medication can aid clients in rebounding from depression. “Medication is mostly used to ease the depressive thoughts and feelings so that the client can more appropriately consider cognitions and take actions that will be productive,” Hazler says.

Walker thinks an antidepressant may be an important adjunct to therapy for some clients. That’s especially true, she says, in cases in which clients are dealing with pervasive depressive symptoms, have a family or personal history of depression, have a history of suicide ideation or attempts, or have a serious medical condition, chronic pain or disability. “However,” Walker says, “I do not necessarily see medications as being the end-all-be-all and believe that a whole-body approach will provide greater efficacy in the treatment of depression. I frequently encourage clients to schedule an appointment with their general practitioner or internist for a full physical and blood work to determine if an underlying medical condition may be contributing to their depression.”

In addition to the chosen counseling approach and possible medications, Walker says wellness is a key ingredient in fighting depression. “[I] have found that when clients engage in a good self-care program, which includes better nutrition, a regular moderate exercise program and keeping a consistent and reasonable sleep-wake cycle, they often report that the intensity, frequency or duration of their [depression] symptoms diminishes,” she says. “I also believe it is important that clients engage in meaningful and productive activity and daily responsibilities, be fully present and engaged in relationships with important others, and participate in leisure activities and recreation to help mitigate their depressive symptoms.”

“Wellness comes apart during depression,” Hazler says, adding that many people experiencing depression tend to decrease healthy life habits such as good eating, exercise, spirituality and sociability. “Not only does not doing these things change body chemistry, [but] the person also knows they’re not doing them, and they feel bad about it,” which can further deepen the depression, he says.

Encouraging wellness is one piece of a holistic approach to helping clients combat depression, Hazler says. “In action, [a holistic approach] means that you deal with the client’s cognitions, work with their actions/behaviors and consider all aspects of the client’s environment, culture [and] the various aspects of wellness,” he says. “Depression is not one-dimensional. It impacts and is impacted by all aspects of the client’s genetics [and] environment and all the aspects of a wellness model that support a healthy life and lifestyle.”

Invisible no more

When it comes to diagnosing depression, says Carlos Zalaquett, professor and coordinator of the clinical mental health counseling program at the University of South Florida, adolescents and older adults are often the most “invisible” populations. Why? With adolescents, symptoms of depression are frequently chalked up to teenage moodiness, while among older adults, the symptoms are often mistaken as a normal part of aging, says Zalaquett, a member of ACA who has conducted research on depression in both groups.

Especially troubling when it comes to depression being overlooked in these two groups — by doctors, by mental health professionals, by loved ones and even by the clients themselves — is that both populations are known to be at high risk for depression, Zalaquett says. According to the National Alliance on Mental Illness, depression affects more than 6.5 million adults age 65 and older in the United States, or more than 18 percent of that population. Information from the National Institute of Mental Health (NIMH) indicates that about 11 percent of adolescents have a depressive disorder by age 18.

Zalaquett, who has trained school counselors throughout Florida on how to separate adolescent moodiness from depression, says counselors need to stay alert for signals that a teenager might be depressed. These signals can include attendance issues, behavior problems, academic problems, inability to concentrate, irritability, withdrawing from classmates and friends, and any expressions of suicide or death wishes. Most adolescents won’t show these symptoms for an extended period of time, but if they do, Zalaquett says, counselors need to get involved or make a referral.

According to NIMH, adolescent girls are even more likely than boys to experience depression. Laura Choate, associate professor of counselor education at Louisiana State University, says major depressive disorder is rising among adolescent girls, perhaps because they are reaching puberty earlier than in the past, are facing life stressors earlier and are less prepared to manage those stressors and pressures. Between the ages of 12 and 15, rates of depression among girls triple, according to Choate. By age 18, she says, 1 in 5 girls will have experienced an episode of major depression, and 1 in 10 will have had at least one suicide attempt.

Adolescent girls are under more pressure today than in the past, says Choate, author of the book Girls’ and Women’s Wellness: Contemporary Counseling Issues and Interventions, published by ACA. Not only are their bodies growing and their hormones changing, but they are also facing pressure to achieve academically and socially and to measure up to often-unattainable ideals fostered in the popular media. Choate says adolescent girls also soak up a message perpetuated by society that they should succeed and be competitive, while simultaneously receiving another message that they should be kind, take care of others and show compassion. So, Choate says, these girls may worry about their friends’ feelings even as they try to compete against them in athletics or academics, for instance.

Girls also are prone to excessive empathy, Choate says. “If their friend is going through a hard time, they allow the friend’s problem to affect them, and they feel it [too],” she says. “That can put them at risk for depression.”

Another factor is that girls are more likely to engage in corumination, repeatedly obsessing over problems verbally with their friends, Choate says. “Yet they’re less likely than boys to problem solve and take action,” she says. “Instead, they just ruminate and talk about the problem, and this process contributes to depression.”

Although most adolescent girls will experience a depressed mood from time to time, Choate points out that the criteria for major depression as set forth in the Diagnostic and Statistical Manual of Mental Disorders (DSM) include having at least five of the nine following symptoms that persist for two weeks or more: depressed mood, loss of interest or pleasure in usual activities, appetite disturbance (decrease or increase), sleep disturbance (insomnia or hypersomnia), psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or guilt, concentration problems or indecisiveness, and suicidal ideation or gestures. These symptoms must represent a change from previous functioning in the adolescent, Choate says, and must produce impairment in relationships or in the performance of typical activities.

Early intervention

Choate says cognitive behavior therapy (CBT) is the theoretical approach for depressed adolescent girls that is most effective and most highly recommended by research. “It really addresses girls’ negative core beliefs about themselves, negative core beliefs about others and negative beliefs about the future that things will never be better,” she says. CBT techniques also address coping skills and problem-solving skills. Choate particularly recommends that counselors check into what she calls the most studied program for adolescent depression — Coping With Depression-Adolescents. Its manual and more information about the approach are available online, she says.

In discussing the possible role of medication in treating depression, Choate points to the Treatment for Adolescents With Depression Study (TADS), a randomized, controlled clinical trial that evaluated the effectiveness of CBT on its own, the medication fluoxetine on its own and therapy involving a combination of both CBT and fluoxetine. In a 36-week study, Choate says adolescents treated with CBT plus medication had the greatest recovery rates. “The TADS researchers reported that combination treatment reached maximum benefit at Week 18 with a response rate of 85 percent,” she says.

When fluoxetine alone and CBT alone were compared, Choate says the medication produced symptom reduction more quickly, but adolescents who received only medication were twice as likely to report suicide ideation. “This concerning finding led researchers to conclude that clinicians may want to begin treatment with CBT alone to avoid risk of antidepressant-induced suicidality and only [add] medication to the treatment regimen if the response to CBT is inadequate,” Choate says. “By starting treatment with CBT, there is no increased risk for suicidality, and adding CBT to medication helps protect from suicidality because it helps the client learn skills for managing stressful events, family conflicts and negative affect.”

In making treatment decisions regarding depression with adolescent clients, Choate suggests that counselors consult with appropriate medical professionals and consider the recommendations provided by the American Academy of Child and Adolescent Psychiatry Practice Guidelines for Child and Adolescent Depression.

Early intervention needs to be a primary focus for counselors, Choate says, especially because providing girls with the skills to prevent the onset of depression during adolescence can protect them from many of the negative outcomes associated with battling depression throughout their lifetime. Among important areas of training for girls are emotional literacy and regulation, stress reduction, social skills, problem solving, cognitive skills, building positive support systems, participation in pleasant events, awareness of mental health issues and knowledge of how to access services, Choate says.

Among the other recommendations Choate provides for working with adolescent girls who are dealing with depression:

  • “Take the depressive symptoms seriously,” she says. “Don’t buy into the stereotype that adolescent girls are just moody and that symptoms should be dismissed as typical teenage behavior if the depressive symptoms are persistent.”
  • Regardless of the theoretical approach taken, address the adolescent girl’s relationships with significant others in her life, including family, peers and romantic partners.
  • Assess her level of activity online. “While most girls report that social networking and texting help them feel closer to their friends, they also report that it can cause them to feel jealous, depressed or sad when others do not respond to their communication in the way they expected,” Choate says.
  • Include her family in treatment. “At this age, she is embedded in her family system,” Choate says. “Family communication, her role in the family and overall family functioning should be addressed in treatment.”
  • Check out prevention programs such as the Penn Resiliency Program, which is an evidence-based program for the prevention of depression in adolescents ages 10-14.

‘Depression is not mandatory’

On the other end of the human development continuum, older adults’ depression symptoms are often passed off as something to be expected as people age, Zalaquett says. “As a society, we value youth, vigor, enterprise and agency, among other characteristics,” he says. “Therefore, the declines in mobility and perceptual skills, as well as in intellectual speed, plus health issues, emptying of the nest and loss of relationships due to death, make observers feel that older adults are unhappy and that later years are depressive years. Moreover, many professionals and nonprofessionals view depression as a condition naturally associated with older age. This is not true, and depression is not mandatory for older age.” As with all other groups of people, Zalaquett says, the diagnosis of major depressive disorder among older adults is determined by classification tools such as the DSM and the International Classification of Diseases.

Although depression should not be viewed as a “normal” condition among older adults, Gintner acknowledges a number of life stressors that often accompany aging can contribute to its onset. For example, he says, older adults are often dealing with medical issues, the loss of loved ones and social support, potential cognitive impairment and life transitions such as retirement.

Gintner says it is also important to point out that undiagnosed and untreated depression can have serious consequences for older adults, including potentially complicating any medical issue and even predicting a shorter life. However, studies have shown that psychotherapy is very effective at treating major depression among older adults, he says.

What is tricky, Gintner says, is separating some of the typical physical problems and symptoms of aging from the symptoms of depression, because they often can mimic each other. For example, he says, adults might automatically attribute forgetfulness, fatigue, loss of interest in activities or loss of appetite to aging. But in fact, those are also symptoms of depression.

In diagnosing depression among older adults, Gintner says counselors must pay close attention and screen carefully. Many older adults grew up in a time when psychiatric symptoms were minimized and hidden, especially if you were a man, Gintner says, so they might remain hesitant to discuss those issues today. Counselors should also be aware of how depressive symptoms might vary at different ages, he says. For instance, among older adults, depression is more likely to be indicated by a loss of interest in certain activities rather than by significant depressed mood.

Gintner says cognitive therapy, behavior therapy and interpersonal therapy each have been shown effective in treating depression in older adults. Cognitive therapy looks at the older adult’s dysfunctional thoughts and beliefs; behavior therapy might aim to increase the frequency of a client’s pleasant events while decreasing the frequency of negative events; and interpersonal therapy would examine how a client’s interpersonal relationships affect his or her mood, Gintner explains.

Medication is also an option for treating depression among older adults, Gintner says, although it is often used more with adults whose depression is in the moderate to severe range rather than in the mild to moderate range. Choosing to add medication to the treatment regime is a matter of preference for clients, Gintner says, and counselors should respect whatever the client’s preferences are.

Whoever prescribes the medication should also be aware of the differences between older and younger adults in terms of the side effects a medication might have, Gintner says. And, of course, antidepressants might also affect or interact with other medications that older clients are already taking. “Counselors need to be aware of the benefits of medication for the elderly but also [be aware of] potential risks so that they can advocate for their clients if they need to,” Gintner says. The obvious benefit of psychotherapy, he adds, is that it has no medical side effects.

Building on client strengths and focusing on wellness are other keys when working with older adults, Zalaquett says. He suggests that counselors talk with clients about healthy eating, age-appropriate exercise, improvement of cognitive skills, maintenance or re-establishment of social and family relationships, and how to find meaning in life.

Gintner recommends that counselors interested in working with older adults on the topic of depression check out their area Council on Aging, make contacts with nursing homes and develop relationships with physicians known to work in gerontology.

Depression during pregnancy

Prenatal women may be considered yet another partially invisible population as it concerns depression. Choate, who co-authored an article on prenatal depression with Gintner for ACA’s Journal of Counseling & Development last year, says postpartum depression has become more well known in part because of media coverage of women who have acted violently toward their children while suffering from postpartum depression. But depression among women who are pregnant is just as common as depression among women who recently have given birth, according to Choate.

The highest rate of depression for women occurs during childbearing years between the ages of 25 and 44, Choate says. It used to be thought that pregnancy offered protection from depression, Choate says, but it has since been found that just as many women are depressed during pregnancy as are depressed after or outside of pregnancy.

It is not known for certain whether biological factors such as hormones play a role in depression among pregnant women, Choate says, but a previous history of depression does make a woman more likely to have a depressive episode during pregnancy, as does a family history of depression. Pregnant women also tend to be processing a variety of potentially emotional topics, Choate says, such as resolving thoughts about the upcoming transition, regardless of whether they are becoming a mother for the first time or becoming a mother again. They may also be dealing with interpersonal issues with their partners, external stressors such as finances and even grief over a perceived loss of independence, especially if the pregnancy was unwanted.

What makes prenatal depression challenging to diagnose and treat, Choate says, is that many of the symptoms of depression mimic pregnancy symptoms, including fatigue, trouble sleeping, mood swings and trouble concentrating. What might help counselors determine if prenatal depression is present, Choate says, is asking a question such as, “If you did experience an increase in energy or you were able to get better sleep, would you be interested in doing the things you normally do?”

Research has not been conducted on CBT techniques specifically with prenatal women, but Choate believes CBT is likely a good approach to use because of its effectiveness with depression in the general population. A manualized form of interpersonal therapy for pregnant women, called interpersonal therapy for pregnancy (IPT-P), does exist. It focuses on interpersonal skills and on the client being able to resolve issues in her personal relationships, Choate says. IPT-P places emphasis on the skills women need as new mothers, such as communicating with their partners, parenting, getting medical care, building a strong support system, resolving issues from their past and preparing to transition into their new role. Preparing for the transition may involve the mother-to-be addressing what she is giving up as well as what she will gain, Choate says.

Counselors treating prenatal clients with more severe depression might want to suggest that these women talk with their physicians and possibly be evaluated for medication. In such cases, Choate recommends that counselors offer to consult with the physician so that all three parties — counselor, client and physician — can weigh the potential side effects of medication to the baby versus the risk to the child if the mother remains depressed.

Building relationships with physicians is important even before a counselor sees a prenatal client, Choate says. She suggests reaching out to doctors and offering to collaborate with them and take referrals if their pregnant patients appear depressed. Women might believe they are automatically supposed to be happy during pregnancy, she says, and feel embarrassed or ashamed when they feel depressed instead. In such cases, they might not seek out a counselor directly.

Counselors who see depressed prenatal clients should be careful not to impose their values or assume that pregnancy is necessarily a happy time for all women, Choate says. “Try to understand her worldview, her role as a future mother and the pregnancy,” she says. “Make sure that you understand the different stressors that are operating in her life. Look at her holistically, not just as a depressed woman or a pregnant woman. Consider all the stressors and strengths in multiple life areas.”

The threat of suicide

All counselors, regardless of specialty or the population with which they work, should understand that depression is a prominent risk factor for suicide. A new report from the American Journal of Public Health revealed that more Americans now die by suicide than die in car crashes. According to health officials, almost 100 people die by suicide every day in the United States.

In September, U.S. Surgeon General Regina Benjamin in September introduced a new suicide-prevention plan with the goal of saving 20,000 lives in the next five years. Medicare has begun covering depression screenings, and Medicare and Medicaid now reward doctors who screen depressed patients for suicide risk.

Choate points out that adolescent girls are at especially high risk for suicide. “Counselors should definitely assess for suicide if the client is taking antidepressant medication,” she says. “Treatment should include helping her become aware of the relationship between her thoughts and feelings and should help her learn skills for distress tolerance, emotion regulation, coping with stressors and problem solving. This will help her better manage suicidal thoughts if they should emerge.”

According to NIMH, older Americans are “disproportionately likely to die by suicide.” Data from 2009 noted by the American Association of Suicidology shows that adults older than 65 made up almost 13 percent of the population but almost 16 percent of all suicides. “Suicide is a significant concern among older adults,” Zalaquett says. “This group has [a higher] rate of suicide [than] any other age group, particularly among men. Counselors working with older adults should assess for depression and suicide risk. We should not take these symptoms lightly or assume they are a necessary component of aging.”

The first step in combatting suicide with any depressed client, regardless of age or stage, is to understand that he or she is in intense psychological pain and wants to get as far away from that pain as possible, Walker says. “It is imperative that counselors listen openly and calmly with their clients who feel depressed and demonstrate that they care,” she says. “Don’t ignore the threats, and don’t be afraid to talk about suicide or the problems that have caused the desire to commit suicide. If a counselor communicates a fear of talking about it, [the counselor] will inadvertently convey to the client that it isn’t OK for them to talk about it either. Sweeping the problem under the rug may cause the client to feel guilty, misunderstood or unaccepted.”

Walker says counselors should assess for suicide risk factors, including the following:

  • History of chronic physical or emotional illness
  • Family history of attempted and completed suicides
  • Losing a significant other or close friend to suicide
  •  Increased anxiety, agitation, rage and emotional outbursts
  • Social isolation, relationship loss or stress, or perceived lack of emotional and tangible resources
  • Isolating and withdrawing from relationships and responsibilities (for example, missing important family events or absenteeism at work)
  • History of impulsivity, poor decision-making or risk-taking behavior
  • History of mental illness
  • History of drug and/or alcohol use or abuse
  • Pervasive and unwavering feelings of hopelessness, worthlessness, helplessness, guilt and/or despair

Walker suggests that counselors also attempt to find out clients’ intent, plans and means to carry out suicide; the frequency, duration and intensity of clients’ feelings; previous suicide attempts, if any; and how hopeless clients feel (using a measurable scale). Counselors can also aim to find out how specific, lethal, available and proximate the suicide plan is, she says. For example, using over-the-counter drugs might be lower risk than using a gun.

“Use closed-ended questions that involve ‘yes’ or ‘no’ answers so you can get a thorough assessment of specific plan and intent,” Walker says. For example, “‘Have your problems been getting you down so much lately that you’ve been thinking about harming yourself?’ and ‘Have you been feeling so hopeless that you’ve been thinking of killing yourself?’ If the answer is yes, the counselor must assess the degree of risk very quickly. Do not ask, ‘Why would you kill yourself?’ Instead ask, ‘How would you kill yourself?’ Talking about it with them will most likely help to bring down the agitation and lower the lethality.”

Help clients verbalize their difficulties and make an “options” list, prioritizing those options from best to worst, Walker suggests. “If they can’t think of anything, help them create alternative options,” she says. “If they absolutely insist on listing suicide as an option, try to get them to list it last. Additionally, help build a network for them and get them to do a verbal … and written contract with you that they will call a crisis hotline before they decide to do anything.”

Hazler warns counselors not to lose sight of the suicide threat as a client’s depression improves. Sometimes, he says, therapy or medication actually provides individuals the little added energy they were previously missing to carry out a suicide attempt.

Offering a lifeline

Walker recalls a depressed older male client she counseled while working at a rural community agency. “[He started] off his first session with me with intense anger,” Walker remembers, “shaking his cane in the air, pounding it into the ground [and] saying, ‘No one wants to help me, no one cares about me, and I have nothing left to live for.’ He didn’t want to be there, but he had nowhere else to turn and knew he needed help. He was at the end of his rope. The week prior to his first session with me, he made the devastating decision to put his dog down because he couldn’t afford to feed it, and [he] felt so alone and lost in life. He had not talked to his adult children in months. He was living with chronic pain, could no longer work and had to survive on meager disability assistance. He felt helpless, hopeless and worthless. He had a definite plan to take his own life and the means to carry it out.”

Walker did a substantial amount of active listening and supporting during that first session. The client could tell she cared tremendously, and he began to trust that she was not going to give up on him. “As a counselor, I believe in the power of human potential and in helping my clients learn to overcome life challenges and trust in their own resiliency,” she says. “I believe in hope and our ability to create meaning in our lives instead of being victims to it.”

Counselors often serve as guides, teachers, coaches, mentors, mediators or lifelines, Walker says. “For this client, I was the lifeline he needed. One test of strength and resiliency was the fact that he had been 20 years actively sober from alcohol. However, as he struggled with his loss of identity as a worker and wage earner, he found himself … in the depths of abject despair. Believing that no one cared and that he was a fraction of a man due to his pain, disability and loss of identity, he had pulled away from his family, friends and the support network he had in Alcoholics Anonymous and with his sponsor.”

Encouraged by Walker, the client agreed to give his gun, which was part of his suicide plan, to a family member, and the family member agreed not to give it back to him. “We tapped into his support network to help serve as a buffer to his emotional pain,” Walker says. “He committed himself to figuring out a way to make sense of it all and to re-create meaning in his life. He began to spend time with his children and grandchildren. He re-engaged in life and reached out to his friends. He resumed weekly AA meetings and began meeting regularly with his sponsor. He began to focus on what he still had in his life and what he could still do with it instead of focusing on what he had lost. Throughout our work together, he learned to not give up on himself and to trust the resources he already had and the resources he could tap into to make it through in life. As he felt stronger, he felt better and began to believe in himself again.”

Walker continues, “There is a great quote by an unknown author that says, ‘When the world says, “Give up,” Hope whispers, “Try it one more time.”’ As a counselor, I believe in hope and I believe in client resiliency, and I believe as counselors, that is our mandate.”

The following individuals interviewed for this article invite readers to contact them:

Want to read more? Click here for an online exclusive Q&A with Carlos Zalaquett on diversity’s role in depression.

Lynne Shallcross is the associate editor and senior writer for Counseling Today. Contact her at

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It’s not all guns and PTSD: Counseling with a cultural lens

Natosha K. Monroe

When one counsels military service members and their families, the existence and impact of military culture on the client and the therapeutic process is an important consideration. Many in our profession are ready and willing to help address the social and psychological challenges that many service members face. These challenges can include marital discord, sleep disturbances, military downsizing, residual effects of combat exposure and mild traumatic brain injury.

On the basis of their years of therapeutic experience, treatment expertise, vast knowledge and the purest of intentions, counselors working with troops have much to offer. What might be missing from some counselors’ practice, however, is cultural competence. When the military culture is not clearly understood or not properly accounted for during provision of services, even the best counselor can inadvertently damage client rapport, limit the quality of care or even misdiagnose.

The idea of the military representing its own distinct culture may not cross the mind of every counselor. After all, the U.S. military is composed of people of many different ethnicities, races, cultures, socioeconomic backgrounds, ages and even countries of origin. It may seem odd to regard a client who is a military veteran as being from another culture when he or she shares commonalities with the counselor such as race, ethnicity or geographical area. However, as defined in the social sciences, members of the military clearly meet the criteria for possessing their own culture.

The term culture is often mistaken as referencing only ethnicity or race. But take the “American” culture, which is unquestionably composed of people from many different races and of many different ethnicities. When an American visits another country, however, others may quickly identify him or her as being “American.” This is because people outside of the American culture notice subtle and not-so-subtle factors that distinguish our culture from their own.

In its glossary of terms, the ACA Code of Ethics defines culture as “membership in a socially constructed way of living, which incorporates collective values, beliefs, norms, boundaries and lifestyles.” Although specific definitions of culture vary depending on the source, cultural components consistently include language, cuisine, music, dress, government, gestures, grooming and technology.

On the basis of those criteria, it is easy to see the influence of military culture on a male Army soldier, for instance. His language includes words and phrases (Charlie Foxtrot, Class Six, jacked up, civvies, rack, FUBAR, Hooah and roger, for example) that differ from those used by other Americans. His dress is the ACU (Army combat uniform). Music on his iPod may include “The Army Song” or even his favorite running cadence. His cuisine for the day may consist of two MREs (meals ready to eat) or something from the “gut wagon” or “chow hall.” His “government” (although still the U.S. government) includes his commanding officer and a court-martial if he is accused of a crime. His grooming is clearly defined by his extremely short, barely there haircut (a mandatory style for which he can face discipline if not adhered to).

The American Counseling Association is not the only professional organization to emphasize culturally appropriate practice. The American Psychological Association also encourages professionals to use a “cultural lens” and to place cultural competence at the forefront of their professional encounters on all levels. It is vital for counselors to keep in mind that cultural factors can have a very real influence not only on the client’s behaviors but on the counselor’s behaviors as well. The counselor who views the client and the therapeutic process through the appropriate cultural lens begins by acknowledging the influences of culture and then approaches work with the military client with increased respect and competence.

In fact, all professional counselors are ethically compelled to obtain and exhibit multicultural competence when working with their clients. The ACA Code of Ethics defines multicultural/diversity competence as the “capacity whereby counselors possess cultural and diversity awareness and knowledge about self and others, and how this awareness and knowledge is applied effectively in practice with clients and client groups.”

When the choice is made to view the military client through the appropriate cultural lens, professionals increase their odds of avoiding many pitfalls in therapy.

Wasting valuable time on content rather than process

A common mistake counselors make when working with military service members is not taking the time to learn basic information such as rank structure and the differences between military branches. For example, the Navy rank of captain is much higher than the Army rank of captain. Another common misconception is that everyone in the military is a “soldier,” when in fact, this term only describes those in the Army. There are also Marines, airmen, sailors and others. The military client will not expect a nonmilitary counselor to know everything about the military lifestyle, but it can quickly become a distraction and an annoyance if the client regularly has to stop to answer a counselor’s questions about the military, clarify a word or phrase, or address the confusion written across the counselor’s face.

These interruptions can, in fact, hinder the therapeutic process for both counselor and client. Consider the following: Military clients become aware that the counselor hasn’t taken the time to get to know basic military information and doesn’t understand their lifestyle. When their focus shifts to explaining basic terminology or having to “dummy down” the conversation for the counselor, they are not able to give themselves over fully to the therapeutic process.

The counselor’s focus is diverted away from the therapeutic process due to the distraction of the content as well. When the counselor’s focus shifts to content in a struggle to understand what the client is saying, the counselor is not able to give himself or herself over fully to the process either, thus not giving the client the level of service he or she deserves.

Stereotypes and bias

Counselors who have never served in the military themselves (and even those who have) should be aware of the potential to stereotype. The media tend to focus on theatrical drama, so extreme cases are often showcased rather than the norm, which is the more resilient, “typical” returning veteran. Exposure to these negative and inaccurate portrayals of veterans in movies and other forms of media is inevitable and can create bias. Self-awareness and consistent self-monitoring on the part of the counselor are vital.

When counselors notice they are quickly jumping to conclusions or patterns of thought, this should be addressed internally. For instance, not all veterans returning from a combat zone have seen combat; not all Marines have killed; not all military wives are stay-at-home mothers; not all enlisted troops are without a college degree; not all clients with nightmares have posttraumatic stress disorder (PTSD); not all troops have been deployed overseas; and, most important, not all counselors are smarter, wealthier, classier, more educated or better adjusted than their military clients.

There can be a fine line between informed multicultural consideration and stereotyping, so it is important to remain clear regarding the differences between the two. It is a good idea to periodically refresh one’s memory of what was learned during that graduate-level multicultural counseling course. It only takes a moment to search an online bookstore to download a book onto an e-reader or to read an article online. At the very least, one can set aside time to conduct a quick Internet search on stereotypes versus bias versus cultural considerations in therapy.

Although much of the difference is defined by intent and accuracy, a counselor can still accidentally possess or exhibit bias toward a military client despite having good intentions and accurate information. Of course, harboring or exhibiting bias — regardless of intent — goes deeper than just being unprofessional and disrespectful. The counselor’s role in the diagnosis of mental disorders is addressed under Standard E.5. of the ACA Code of Ethics. Standard E.5.c. speaks to the more specific dangers that lingering bias and stereotyping may have in our profession, making it vital for counselors to be culturally competent: “Counselors recognize historical and social prejudices in the misdiagnosis and pathologizing of certain individuals and groups and the role of mental health professionals in perpetuating these prejudices through diagnosis and treatment.” This is a hefty ethical principle — one that probably should be read several times and taken to heart to emphasize how important our role as counselors can be in someone’s life and in society.

Misinterpreted affect or expression

At times, the military client may exhibit a lack of expression that appears robotic or cold to the point of seemingly justifying the descriptive “blunted affect.” At other times, the client’s tone, rate of speech, emotion or expression might seem off or inappropriate. But is this truly “off,” or does the client’s expression differ from the “norm” because of cultural factors?

In the military culture, displaying emotion or lack of control is commonly viewed as weakness, while composure is regarded as strength. For example, a Marine would most likely be shunned or even disciplined for being visibly confused or breaking down and crying in front of others. So, what the counselor perceives might just be the client attempting to appear composed according to the norms of the military culture.

It may also appear to the counselor that the military client is disconnected or otherwise acting inappropriately if the client comes across as unremorseful or emotionless when describing a situation in which the client killed another individual. But before passing judgment or reaching a conclusion, the counselor must also consider the situation in which the killing occurred and how this might affect the client’s reaction. Although it might be a difficult concept to grasp, the context of death in military culture can differ, thus potentially influencing reactions and expressions of emotion.

Should killing in war automatically elicit guilt? What about in cases of self-defense? What about to ensure survival? What about if the act was committed to save a child’s life or to stop a rape? When should a counselor be concerned about the military client displaying (or not displaying) a certain emotion? When should a client’s reaction be questioned and brought to his or her attention?

The counselor must understand military culture and, more important, must know the client very well to correctly interpret what is going on and what is appropriate or inappropriate. This is part of what makes the practice of counseling necessary, albeit challenging. It requires not only knowledge, experience and skill, but also the ability to connect with another individual in a way that is unique to his or her profession and interaction style.

Misdiagnosis and inaccurate assessments

Clearly, not all veterans who have nightmares have PTSD, although many professionals jump to this conclusion, neglecting the rest of the criteria in the Diagnostic and Statistical Manual of  Mental Disorders that must be met to justify the assignment of this disorder. Although it may become standard practice to automatically screen every service member for PTSD, it is irresponsible to assume the majority of military clients will have the disorder. Another mistake is to put too much faith in assessment tools that were standardized on nonmilitary populations. For example, many responses provided by someone in a combat zone to questions on the Minnesota Multiphasic Personality Inventory would surely indicate abnormal personality traits, but in fact, the responses would be quite normal given the person’s environment and culture.

A prevalent issue with service members is sleep disturbance and nightmares. Counselors could jump to the conclusion that sleep disturbance results from exposure to combat or other potentially traumatic events when, in fact, different factors might be the culprits. For example, if the client is an airman, he might live near an airfield where jets are repaired at night, making it difficult to sleep. Or the client’s work schedule may have flipped from the day shift to the night shift recently. Another common experience on deployments or while living on military installations is shared living spaces, where sleep is disturbed by roommates making noise or coming and going at all hours of the night.

It might be simpler to highlight “post-combat nightmares” and even recommend pharmaceutical treatment, but to do so without thoroughly exploring the many other possible contributing factors is shortsighted and may result in poor quality of service to the client. It is important that counselors take their role in diagnosis seriously and consider the impact on the client. An overwhelming percentage of military clients walking through the door should not have the same one or two mental health disorders.

Especially in certain work environments such as military installations or Veterans Affairs hospitals, what is written in a service member’s records will, unfortunately, be provided to many people. Privacy is not as much of a luxury in the military as it is in the civilian world. It is a sad reality that a service member’s supervisor or leadership may see mental health care service (especially diagnosis) as a weakness or even use this information against the service member.

As more professionals in our field begin working with the military, cultural competence must be emphasized and given appropriate consideration. Thanks largely to the efforts of ACA and counseling professionals passionate about offering services to military members and their families, jobs are slowly opening up that used to be offered exclusively to social workers and psychologists. Although there are rarely prerequisites (such as graduate program requirements) to one’s first job working with military veterans, counselors must continue seeking ways to broaden their knowledge and deepen their perceptions of the military culture. Seeing things through the cultural lens will help to ensure a stronger foundation for therapeutic relationships and quality service between professional counselors and their military clients. u

Knowledge Share” articles are based on sessions presented at ACA Conferences. Natosha K. Monroe has been an Army behavioral health specialist for more than a decade. Her work has included assignments to Afghanistan, Guantanamo Bay, Haiti and the Pentagon. She advocates for increased hiring of professional counselors to work with veterans and for obtaining recognition of the counseling profession in all military branches. She currently works as a contracted researcher/analyst on a project for the FBI and lives in Northern Virginia. Contact her at

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