Monthly Archives: April 2015

Motivation to change

By Stacy Notaras Murphy April 27, 2015

A 40-year-old man enters counseling to deal with “relationship issues.” He says his marriage is failing due to his use of online pornography and that his financial situation is in constant peril because of high gambling debts. He adds that he drinks alcohol daily and fears he is dependent on it to remain functional.

In terms of treatment triage, many clinicians would choose to make his alcohol dependence a top priority because active substance addiction can make other goals impossible to achieve. But Motivation_smallsubstance abuse work is a significant undertaking. It is not unheard of for a treatment plan to include group therapy, family therapy and an inpatient treatment facility. With the focus of treatment squarely on alcohol use, the client’s other issues may linger on the back burner indefinitely.

It could be a mistake to leave addiction to certain behaviors — such as this client’s compulsive gambling or use of online pornography — out of the treatment plan, says American Counseling Association member Mary Crozier, associate professor and coordinator of the substance abuse counseling certificate program at East Carolina University (ECU) in Greenville, North Carolina. “Just as we’ve adapted to the presence of co-occurring disorders, we are adapting to the presence of behavioral addictions with mental illness and other addictions,” she says, although adding that the dearth of prevention research and services that target behavioral addictions is a significant obstacle. But like most paradigm shifts, the connection between substance abuse and behavioral addiction is slowly coming into focus.

A new book that delves into the diagnosis and treatment of behavioral addiction, The Behavioral Addictions, edited by Michael S. Ascher and Petros Levounis, makes the case that certain behaviors can turn into addictions that follow similar paths to substance use disorders. Levounis, chair of the Department of Psychiatry at Rutgers New Jersey Medical School, tells Counseling Today that behavioral addictions should be viewed as a new field of study encompassing “a number of diverse conditions, from the more traditional problems of gambling, sex, Internet, food and shopping to emerging constructs such as work addiction, love addiction and addiction to indoor sun-tanning.”

Although gambling addiction is the only behavioral addiction found in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), clinicians and researchers are noting that the neurobiological responses to behavioral addiction are similar to those of substance abuse. At the same time, treatment options must be more nuanced for behavioral addictions. For example, alcohol abuse may be treated through abstinence, but food addiction and sex addiction are related to typical human activities for which complete self-denial is an unrealistic goal.

It wasn’t until Crozier had already completed her doctorate and taken a teaching position at Medicine Hat College in Alberta, Canada, that she truly saw for herself the relationship between substance and behavioral addictions. “[The college’s] addictions counseling program integrated substance and behavioral addictions into each course,” she says. “Their model allowed students to see the interactions between substances and behaviors and to really learn about well-researched, prevalent behavioral addictions. Examples of this integration were to weave binge eating disorder into the counseling course, pathological gambling into the assessment course and hypersexuality disorder into the prevention course. Needless to say, I learned a lot and saw addictions in a new light.”

Crozier’s research partner, Shari Sias, a member of ACA and its division, the International Association of Addictions and Offender Counselors (IAAOC), also had a postgraduate awakening to the connection between substance abuse and behavioral addiction. While serving as the clinical coordinator of an outpatient substance abuse counseling center, she and her staff noticed that the clients were also struggling with behavioral addictions. “Once the chemical addictions were addressed, their behavioral addictions began to surface,” says Sias, now an associate professor and director of the substance abuse and clinical counseling programs at ECU. “Staff began asking for training in behavior addictions, and we asked [sex addiction expert and author] Patrick Carnes to come and lead a training. This was an eye-opening experience for all of us, and [we] started incorporating behavior addiction information as part of the outpatient program.”

Complex presentation

As is the case with most disorders, clients struggling with behavioral addiction often present to counseling for other reasons. Crozier is careful to note that not everyone who engages in potentially addictive behaviors actually becomes addicted. She explains that some people come to counseling simply for advice about managing those behaviors.

“Other clients are unaware that their compulsive behaviors are causing risks and negative ripple effects for their friends, family, boss, etc.,” she says. “There seems to be a strong correlation between behavioral addictions — especially pathological gambling — and substance abuse. Many clients thus present to counseling with substance, familial, social, financial, health and occupational challenges.” For this reason, Crozier advises counselors to conduct assessments on behavioral addictions with all clients, both as part of a stronger initial screening process and intermittently thereafter.

Sias agrees. “Most of the clients I’ve counseled sought services due to a chemical addiction, and as part of that work … became aware of a process addiction,” she says. “It is important that behavioral addictions be included in the assessment and treatment process. If we as counselors don’t ask about it, clients may not be aware of the need to treat both the chemical and behavioral addiction.” Sias adds that successful treatment may address both the chemical and behavioral addictions as part of a holistic, client-centered plan, including referrals to other support professionals, such as financial counseling for gambling debts or medical care for binge eating disorder.

Levounis thinks the role of the counselor in helping people who struggle with behavioral addiction is two-fold. “On one hand, she or he is in a unique position to recognize the signs of these poorly understood — and, in general, poorly researched — addictions,” he says. “On the other, the counselor may be able to reformulate a person’s problem in terms of an addictive process, beyond the traditional structures of CBT [cognitive behavior therapy] and psychodynamic psychotherapy.” He provides the example of a person reeling from a series of unsuccessful relationships. The client may find it helpful if her or his counselor reconceptualizes the struggle in terms of unrelenting cravings for the euphoria of a new romance.

“In other words, in terms of an addiction to love,” Levounis says.

Motivational interviewing: A collaborative conversation

There is some good news for counselors who want to start assessing and treating for behavioral addictions and who are experienced in working with clients facing substance abuse issues: These counselors likely already possess the required skills. The evidence-based approach used in motivational interviewing can be refocused to help clients deal with behavioral addictions as well as substance abuse. In fact, none of the counselors interviewed for this article think that motivational interviewing is better used to address one kind of addiction over another. Their general consensus was that, because of its Rogerian, person-centered emphasis, motivational interviewing is useful with anyone considering behavior change of any kind. In their book, Ascher and Levounis point out that due in part to the absence of DSM-5 diagnoses for most behavioral addictions, motivational interviewing joins individual and group psychotherapy and self-help groups as one of the few current treatment recommendations for these disorders.

“[Motivational interviewing’s] client-centered counseling style for eliciting behavior change and helping clients explore and resolve ambivalence is great for meeting clients where they are in the change process,” Sias says. In her experience, she also has found that motivational interviewing increases client attendance and retention rates. “We know the longer clients remain in treatment, the better the recovery rate,” she adds.

Melanie M. Iarussi, an ACA member and secretary of IAAOC who is also an assistant professor at Auburn University in Alabama, is a trainer with the Motivational Interviewing Network of Trainers (MINT) organization. She has used motivational interviewing in a variety of clinical settings, including substance abuse treatment centers, college counseling centers and a domestic violence intervention center. She defines motivational interviewing as a humanistic, goal-oriented approach designed to help people identify and strengthen their personal motivations to engage in behavior change. “The humanistic underpinnings of the MI [motivational interviewing] approach made complete sense to me, and using MI strategies gave me some tools to promote engagement in counseling and enhance problem awareness with my clients,” she says.

Motivational interviewing encourages the counselor to engage in a collaborative conversation that meets clients where they currently are. The approach avoids imposing beliefs or forcing change on the client. “Instead, MI is grounded in respect and valuing the client with all of his or her experiences and wisdom,” Iarussi says. “MI emphasizes empathy — truly seeing the issues and concerns through the eyes of the client, taking into account his or her worldview, background, resources, etc. — and it requires a unique, responsive approach to each individual.” She adds that MI counselors support client autonomy, affirming the individual strengths and assets that can be a foundation for making positive changes.

When treating behavioral addictions, Iarussi has found that motivational interviewing works well in tandem with other therapeutic approaches. For example, she says, clients with behavioral addictions can benefit from a combination of motivational interviewing and CBT. “MI can help the person cultivate and enhance their motivations to pursue behavior changes, and then CBT can help them develop the skills and tools needed to implement the change,” she explains.

Iarussi cautions, however, that challenges may arise when the client perceives that the behavior provides more benefits than costs or when resources are lacking for the client to implement and sustain change. If the counselor and the client collaboratively explore the possibility of change and the client decides against it, the MI protocol calls for the counselor to honor the client’s autonomy and decisions. “We can express concern in a genuine, compassionate manner, but we do not attempt to coerce or force change upon clients,” Iarussi notes. “In the end, it is truly their choice if they will change their behavior. … The counselor acts as a guide.”

Iarussi goes on to explain that when there is a lack of resources contributing to the inability to change, the MI counselor helps the client manage with whatever resources are available. Creativity is useful here, she says. For example, consider a client who struggles with hypersexual behavior who would benefit from attending a 12-step meeting. If the client lives in a small community without close access to such a meeting, the counselor and client could work together to brainstorm options such as online meetings, committing to travel to a meeting far away at least twice a month and so on, Iarussi says.

Within the community of addictions counselors, motivational interviewing is now a widely accepted tool for working with behavioral or process addictions, according to Paul Toriello, an ACA and IAAOC member and MINT trainer who serves as director of graduate studies in the Department of Addictions and Rehabilitation Studies at ECU. In fact, Toriello says that most of the motivational interviewing trainings he currently runs are outside of the substance abuse arena. “MI was in many ways born in a substance abuse setting, but it has evolved for so many years,” he says, noting that his current work involving motivational interviewing is in career motivation with wounded veterans.

Toriello says motivational interviewing’s strong basis in research also has garnered interest in recent years from organizations that need to incorporate evidence-based practice into their treatment planning for funding reasons. “MI checks the box in terms of evidence-based practice, but it is also very fulfilling to practitioners,” he says. “People get into counseling [work] because they want to build relationships, and if I can do that and, at the same time, meet the demands of funding agencies and insurance companies, it’s hard to lose.”

Specifically, Toriello has found motivational interviewing useful in helping clients with behavioral addictions such as gambling and disordered eating. “You name the target behavior, and MI can be done the same way,” he says. “Now there is a lot of variance within [it] … but the approach to behavior X, Y or Z will essentially be the same, guided by the four processes.”

Finding clients’ humanity 

The four core processes of motivational interviewing are engaging, focusing, evoking and planning. Moving through these four stages, counselors aim to guide their clients toward developing their own motivations to change a behavior. Starting with engagement, counselors work to create the therapeutic alliance that is found in most counseling approaches.

Toriello says the framework offers significant flexibility for counselors to follow their own unique paths. He describes it as almost dancelike: “I am strategically asking questions and making reflections so my client will come to a different decision about the behavior he [or she] wants to change. The word you often see is [that MI counselors use] an ‘evocative’ spirit to draw out of the client [his or her] own natural resources for change. That’s one of the things that makes it so person-centered. The interviewer has a sense that everything the client needs to make the change is already within them. It’s the interviewer’s job to bring that out of them, with skillful questioning.”

Toriello offers the example of an adolescent male he worked with in a residential environment years ago. Conduct disorder, angry outbursts and substance abuse were the norm in the facility, and “Johnny” presented with all the symptoms from day one.

“He came in like a bat out of hell,” Toriello recalls. “He just hit the ground running, throwing, spitting, kicking, you name it. Until one day, some time had passed after he went through a crisis period, and I brought him [into my office] and pulled his record. I talked to him to try to get a sense of where he was coming from. [I used] open-ended questions as opposed to confronting or prescribing, and he didn’t act up and he was actually responding, which was cool to see. This got to a point where he broke down, shed a bunch of tears and we implemented some tools he could take with him. He was not an angel, but once we tried to just listen, as opposed to confront, it was working.”

Toriello says that experience set him on a course to learn more about motivational interviewing. “I came from that other model, where you tear down the defenses first. But [with Johnny] I could see, ‘Wow, there is a human being in there!’ But what got us to see that was to act like human beings [ourselves] rather than like power and control mongers,” he reflects.

Challenges ahead

From Sias’ perspective, the biggest challenge for counselors working with the behavioral addiction population is not the clients’ needs but rather having access to services that actually address these disorders. “We need more programs that focus on behavioral addictions, and I think existing substance abuse treatment programs need to integrate behavioral addictions,” she says.

Despite the challenges, she adds that there are many rewards in working with this population. “Counselors trained to address both chemical and behavioral addictions are providing holistic care that makes a big difference in the lives of the clients we serve,” Sias says. “Being part of the change process with clients is an amazing experience.”

Crozier was a member of the IAAOC Process Addictions Committee when it conducted research on the topic of counselor readiness for working with behavioral addictions. The findings from the 2014 nationwide survey of counseling students, faculty and professionals suggest that few counselors are formally trained in process or behavioral addictions; scant research is readily available; and the empirical studies that are available aren’t being widely utilized. Given those findings, Crozier recommends that all counselors join IAAOC’s Process Addictions Committee and read its newsletter.

On a more personal level, Toriello can foresee challenges for new clinicians as they face behavioral addictions in their offices. “You can’t go through a counselor education program and not be steeped in Carl Rogers and the person-centered approach, so these new counselors have the knowledge,” he says. “[But] I am concerned about their strength to implement that knowledge and stay true to person-centered approaches as opposed to succumbing to the pressure … of prescriptive techniques, where they start giving unwanted or unrequested advice, or they start problem-solving and not counseling.”

Toriello fears that counselors have taken too much control of the change process. He believes they would do well to use various techniques, including motivational interviewing, to return that control to their clients, thus allowing them to be the experts on their own issues.




Additional guidance

The International Association of Addictions and Offender Counselors, a division of the American Counseling Association, was chartered in 1972. Members of IAAOC advocate for the development of effective counseling and rehabilitation programs for people with addictions. For more information, visit

Robert L. Smith’s book, Treatment Strategies for Substance and Process Addictions, published earlier this year by ACA, features sections by various authors on pathological gambling, sexual addiction, disordered eating, work addiction, exercise addiction, compulsive buying/shopping addiction and Internet addiction. For more information, visit or call 800.422.2648 ext. 222.

A podcast on “Gambling Addiction,” delivered by Pete Pennington, is available on the ACA website.




Contributing writer Stacy Notaras Murphy is a licensed professional counselor and certified Imago relationship therapist practicing in Washington, D.C. To contact her, visit

Letters to the editor:

Fresh thinking on old issues

By Laurie Meyers April 23, 2015

Trauma, suicide and bullying are not new topics for most counselors, who at some point in their careers have likely worked with clients on each of these issues. However, as research and practice Paint-Splatter_Brandingcontinue to progress, some counselors are using emerging approaches or perspectives to tackle these problems.

At the American Counseling Association’s 2015 Conference & Expo in Orlando, Florida, Counseling Today attended several sessions that presented some of these fresh approaches. We then caught up with three presenters after their sessions to get a more in-depth look at their ideas so we could share them with readers.

Complex PTSD

As far back as the ancient Egyptians, the chronicles of war have noted trauma-induced psychological symptoms. Samuel Pepys wrote about them in the wake of the Great Fire of London. Historians think that the author Charles Dickens may have experienced them after a horrific train accident. We now know these symptoms as indicative of posttraumatic stress disorder (PTSD), but until relatively recently, the cause of trauma-induced behavioral changes was thought to be purely internal and was sometimes even referred to as cowardice.

Trauma-induced psychological symptoms were not officially labeled as a disorder until 1952, in the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which identified it as “gross distress reaction.” However, in 1968, as the memory of World War I and World War II faded, the diagnosis was dropped from the DSM. It wasn’t until scores of Vietnam veterans returned with severe psychological trauma that researchers began a deeper examination of the condition and its causes. The term PTSD officially entered the lexicon in 1980 with publication of the DSM-III. Defined, in essence, as a common set of symptoms brought on by extremely traumatic events such as combat, natural disasters, accidental disasters or personal catastrophes, PTSD has more recently gained greater recognition, both in mental health circles and the public eye, because of the struggles of veterans returning from the wars in Iraq and Afghanistan.

At the same time, many mental health experts have come to believe that another, more common, form of trauma exists that is often misdiagnosed as PTSD. Referred to as complex trauma or complex PTSD, this type of trauma is caused by repeated exposure to abuse or other traumatic events over time.

Despite the urging of many trauma experts, complex trauma was not included in the DSM-5. However, the disorder is very real and distinct from the current definition of PTSD, asserts Cynthia Miller, an ACA member who presented on “Recognizing and treating complex PTSD” at the ACA 2015 Conference.

Complex PTSD is typically the result of cumulative trauma and abuse that started in childhood. Miller’s interest in complex PTSD was first piqued when she was counseling women in the corrections system, where many of her clients — and many of the incarcerated women in general — had histories of trauma and childhood abuse.

“I got interested [in complex PTSD] in my work with the prison population, but even in my community work, I saw that histories of trauma were way more common than we realized and also at the root of so many things that we were treating,” she says.

Clients with trauma histories are often misdiagnosed not only with single-incident PTSD but also with borderline personality disorder, bipolar disorder or major depression, Miller says. These disorders — along with alcohol and substance abuse — can accompany complex trauma, but counselors need to understand that the trauma colors everything the client is experiencing, explains Miller, a licensed professional counselor with a private practice in Charlottesville, Virginia. At the same time, treating complex trauma by immediately turning to protocols for PTSD, such as eye movement desensitization and reprocessing (EMDR), prolonged exposure therapy and cognitive processing therapy, is not going to work as well and may actually result in retraumatizing the client, she says. Methods such as EMDR may be helpful for some clients later in the treatment process, Miller says, but only after they have been through an initial stabilization process.

“One of the most common mistaken impressions [when treating trauma] is that someone who has been through trauma needs to talk about and process it,” explains Miller, who is also an assistant professor of counseling at South University in Richmond. By doing this, she says, “counselors are trying to help clients, but they [may] open up trauma that neither the counselor nor the client is ready to deal with. When dealing with complex trauma, the first thing you need to do is to help them live in the present, not the past.”

Although PTSD and complex trauma share certain symptoms, they also feature significant differences — differences that are crucial for counselors to understand, Miller says.

PTSD is typically caused by a single or time-limited event. Its symptoms include intrusive thoughts, avoidance behaviors, negative alterations in mood and cognition, and alterations in arousal and reactivity.

Complex trauma, on the other hand, is caused by long-term traumatic experiences such as child abuse, intimate partner violence, community violence (including living in a society at war), experiences as a refugee or displaced person, trafficking and forced servitude, chronic illness and disability necessitating invasive treatment, and bullying. Symptoms may partially mirror those for PTSD but also feature additional severe problems such as:

  • Difficulty regulating emotions
  • Disturbances in attention and consciousness
  • Affect dysregulation
  • Altered self-perception, including feelings of guilt and worthlessness
  • Difficulty interacting with other people
  • Chronic dysphoria or dissociation
  • Engaging in self-destructive behavior
  • Difficulty with self-soothing

People who are experiencing complex trauma do not have the emotional skills necessary to address the issues they’re facing, so before moving forward, a counselor must first help the client to stabilize, Miller says. Stabilization begins with establishing a sense of safety, including addressing the client’s most basic needs.

“You really almost have to go through Maslow’s hierarchy with [these clients] to find out if food, clothing and shelter are concerns,” Miller says. “If so, how can you help the client address it? Because it’s hard for someone to build skills if they don’t have a place to sleep.”

After the client’s basic needs have been addressed, the counselor should help the individual establish a sense of safety with “self,” Miller explains. This requires the counselor to probe for self-injurious behavior, suicidal behaviors or urges, risky sexual and other behaviors, and attendance to the health and integrity of the body. Assessing for self-protective behavior is also important, Miller continues. For example, is the client locking his or her house or bedroom door at night? Does he or she go running alone at night in crime-ridden areas? Safety with others is also important, she notes. For instance, is the client in a relationship in which he or she is being abused or exploited?

The third element of safety — without which the counselor cannot help the client with the first two — is feeling safe in therapy, Miller emphasizes. The client must feel that he or she is in control of what is going on.

“There must be a mutually designed treatment plan, informed consent throughout and the promise that the therapist is not going to do anything that the client doesn’t want to do or push them into doing something that they don’t want to do,” Miller says.

As the counselor and client address safety skills together, they should also work on other stabilization elements, such as reducing the acuity of trauma symptoms, Miller says. Symptom reduction involves developing coping skills and may or may not include medication, she adds.

Miller has found that dialectical behavior therapy (DBT) is particularly effective when teaching clients emotional coping skills. DBT helps clients learn that their symptoms are not their fault but rather a natural reaction to what has happened to them. This helps remove the attendant stigma and the clients’ sense that something is really wrong with them, Miller explains.

Because complex trauma causes dissociation, dysphoria, physical agitation and cognitive distortions, grounding skills — both physical and mental — are essential for reconnecting clients with themselves and their surroundings, Miller says. For instance, when a client’s nervous system is overloaded or aroused, his or her cognition is disrupted. To help these clients ground and re-engage, Miller directs them to say their ABCs backward, name the 50 states and state capitals, or name the different makes of automobiles.

To counteract physical disruption and the dissociation that sometimes accompanies it, Miller teaches clients grounding methods that engage the senses, such as touching physical items that have texture, describing what they see in their immediate physical surroundings or listening to soothing music. She also suggests physical stretching and movement, even if it’s just having clients stomp their feet while sitting down, or the sensory experience of running warm or cool water over their hands.

Miller also uses other soothing strategies such as safe place imagery with clients who have complex PTSD. Clients imagine a place, real or imaginary, where they feel safe, and Miller asks them to put themselves there by describing what they see, hear, feel, smell and taste.

Another soothing visualization technique involves picturing a nurturing and protective figure who has made the client feel cared for. Miller says this might be a relative, a friend, a pet or even a fictional or spiritual figure, just as long as the client can envision this figure during a time of need.

Clients with complex trauma also struggle with intrusive thoughts, so Miller asks them to visualize a container — whether it is a box, a safe, a vault, a dumpster or a tractor trailer — that is big enough to hold all of the things that disturb them. “It has to be as real as possible, and they have to be able to ‘lock’ it,” she says. Miller directs clients to visualize the container, set it aside and then walk away. “When they walk away, I have them walk to their visualized safe place,” she says.

Clients who are struggling with complex trauma also need to learn to relate to themselves and to others in different ways, Miller says. DBT can help in this area by teaching clients skills for managing intense emotions and interpersonal relationships. These skills include distress tolerance, emotional regulation, mindfulness and greater interpersonal effectiveness.

After clients are stabilized and feel safe, counselors can help them to integrate their traumatic memories so that the clients are no longer controlled by these memories, Miller says. She emphasizes that the aim of integration is to resolve the traumatic symptoms without retraumatizing the client.

Miller cautions that counselors should proceed carefully, helping the client to re-evaluate the meaning of the trauma and having the client demonstrate the ability to remember experiences while still remaining physically, emotionally and psychologically intact. The re-evaluation may involve an organized recounting of events using methods such as prolonged exposure therapy, cognitive processing therapy, narrative exposure therapy, traumatic incident reduction, EMDR and art therapy, she says.

After successfully stabilizing and integrating traumatic memories, the client and counselor can then work on enhancing the client’s relationships and planning for the future, Miller says.

Miller reiterates that complex trauma is more common than most helping professionals might realize, so she recommends that counselors screen for it routinely. “Counselors should be prepared. … Clients are not necessarily going to tell them [about their trauma] right away,” she says. Even if clients do bring up traumatic experiences on their own, it’s unlikely that they will reveal everything to a counselor initially, so counselors need to create a safe space and be patient, Miller says.

Miller adds that if a counselor suspects a client is experiencing complex trauma, the counselor should ask about it — but carefully. “Ask behaviorally,” she says. “Don’t ask clients if they were physically or sexually abused. Instead, ask them if anyone has ever punched, slapped, kicked or touched [them] in a way that [they] didn’t like or want.” Initially, clients struggling with complex trauma may not recognize or be willing to identify these behaviors as abuse, Miller says.

Because the trauma focus in counselor education is typically on PTSD and not complex trauma, Miller urges counselors to seek further training through continuing education and conferences. “It’s one of those things that you can’t afford not to know about and not know how to treat because, whatever work you do, you’re going to see it,” she says.

Understanding and assessing clients who are suicidal

It’s a counselor’s worst fear: a client who dies by suicide. Yet, as any counselor knows, there is no research that can definitively tell practitioners how to prevent suicide. But what if prevention starts with acceptance rather than assessment? What if connecting with a client who is suicidal requires accepting and understanding that there are circumstances under which many people might consider suicide? These are the questions that ACA member Eric Beeson explored in his conference session, “How do I know if someone is suicidal? A discussion of suicide theory, attitudes and interventions.”

Beeson, a licensed professional counselor and lecturer at the University of North Carolina-Greensboro, thinks that accepting the validity of such feelings is key to understanding why a client believes suicide is the answer. When faced with a client expressing suicidal thoughts, many mental health professionals instead focus on immediately shutting those thoughts down, he says. Although acknowledging there are certain cases that require emergency treatment such as hospitalization, Beeson says an immediate focus on preventing suicide may actually alienate the client and hinder treatment. He believes that approach is often based in the mental health professional’s fear — not only of losing a client but also of having to deal with and consider the subject of suicide. To understand and, hopefully, redirect a client’s suicidal urges, counselors must first examine their own attitudes, he asserts.

Beeson started asking such questions early in his counseling career during a four-year stint at a hospital, where dealing with death and the aftermath of suicide attempts was a regular occurrence. “Watching the way some of the staff interacted with people after a suicide attempt, some of the judgments I saw, got me curious about people’s attitudes toward suicide and then, eventually, how … that attitude influences practice,” he says.

With more than 41,000 reported suicides in the United States in 2014, these are urgent questions to answer. Beeson, a contributing faculty member at Walden University, began his presentation by asking attendees to consider the following questions as a way to examine their own attitudes about suicide and people who die by suicide.

  • How can I tell if my client is suicidal?
  • Why do people attempt or die by suicide?
  • Is suicide a singular event or a process?
  • Can suicide be rational and/or permitted?
  • What is my role when working with someone experiencing suicidal behaviors?
  • Am I capable of suicide?
  • Even though you would prefer another way to die, painful circumstances in life might lead to suicidal ideation. How do you estimate the probability that you sooner or later will die by suicide?

a) I am sure I never will die by suicide.

b) I hope I will never die by suicide, but I am not absolutely sure.

c) Under certain circumstances, I consider suicide as a possibility.

d) I consider suicide as a possibility for the future.

n  What suicide attitudes do you think are most helpful to counseling practice?

a)  More/less acceptance of suicide

b)  More/less condemnation of suicide

c)  More/less belief in the preventability of suicide

Beeson notes that even within the mental health field, the stigma and avoidance surrounding suicide remains strong. People who have died by suicide or attempted suicide are typically viewed as weak. This represents an empathy gap — one that counselors need to close, Beeson asserts. So, he challenges counselors to ask themselves about their personal suicide potential.

During his session, Beeson used humor to demonstrate circumstances that might cause a person to consider suicide as a viable option. In a clip from the old TV sitcom Cheers, four characters — Sam, Woody, Norm and Cliff — are preparing to sky-dive. But when the time comes to jump, they’re all petrified, realizing that they could die. Suddenly, skydiving doesn’t seem like such a good idea. However, for various reasons — to prove something, to not look like a coward, because everyone else is doing it — they each eventually jump. Cliff is the last and the most hesitant. Seemingly nothing will make him jump. But then the plane starts to sputter and the pilot says it’s going to go down. Cliff decides to take his chances — to, in essence, take control of how he will die — and jump.

Beeson asked the audience to think about which character they identified with. What might motivate them to get out of that plane? Beeson says he does this to help counselors recognize that under certain circumstances, anyone might consider dying by suicide. In turn, that helps them better understand why a client might consider suicide a viable — or even the only viable — option.

Beeson notes this is not just theoretical for him. During his time working with clients who were suicidal, he found that the more he focused on prevention, the less effective he was. However, once he started focusing on acknowledging the client’s struggle and the resilience it had taken to come this far, he was better able to take that resilience and direct it toward other methods of coping.

“I don’t know what it’s like for … any person to walk in their shoes, and who am I to say that they’re walking in their shoes wrong?” Beeson asks. “Who’s to say if I wasn’t in a similar situation, that my shoes might get a little uncomfortable? … And [if they] become more uncomfortable than I’d like to bear and I can’t find a new pair of shoes, then who’s to say that I might not take those shoes off?”

“I don’t believe that people just want to kill themselves,” he says. “It’s just that last-ditch effort to attain something that seems unattainable.”

Beeson believes counselors need to view suicidal intent on a continuum. “Suicidal is a misleading term. There’s no research to suggest that there’s any way to truly decide when someone is or is not — quote, unquote — ‘suicidal,’” Beeson says.

The better question, he asserts, is how likely is someone to die. Dying is painful and goes against the natural human instinct to preserve life. Beeson explains that research by psychologist and suicide expert Thomas Joiner posits that suicide requires overcoming that instinct and becoming capable of killing oneself. When that capability is combined with circumstances that seem intolerable, the risk of suicide is very high, Beeson explains.

Some people, such as those in high-risk, high-intensity jobs, including police officers, firefighters and emergency services personnel, already have a greater risk of death because they are regularly exposed to and habituated to it, Beeson contends. In addition, people in these jobs are routinely exposed to others’ experiences of pain. This engenders a certain comfort level with pain that also increases the person’s likelihood of dying, Beeson says.

But working in one of these high-intensity professions is not the only way that people habituate themselves to pain and the risk of death. Nonsuicidal self-injury, prior suicide attempts, intravenous drug use and prostitution have all been linked to suicidal behavior, Beeson says.

He adds that research by Joiner and others has shown that suicidal risk factors fall under three main categories.


  • Mental disorders — particularly mood disorders, schizophrenia, anxiety disorders and certain personality disorders
  • Alcohol and other substance use disorders
  • A sense of hopelessness
  • Impulsive or aggressive tendencies
  • History of trauma or abuse
  • Some major physical illnesses
  • Previous suicide attempt
  • Family history of suicide



  • Job or financial loss
  • Relational or social loss
  • Easy access to lethal means
  • Local clusters of suicide that have a contagious influence



  • Lack of social support and sense of isolation
  • Stigma associated with help-seeking behavior
  • Barriers to accessing health care, especially mental health and substance abuse treatment
  • Certain cultural and religious beliefs (for instance, the belief that suicide is a noble resolution of a personal dilemma)
  • Exposure to suicide, including through the media, and the influence of others who have died by suicide

Beeson says counselors should evaluate clients for these risk factors and also look for the following warning signs.

Talk: The client talks about killing himself or herself, having no reason to live, being a burden to others, feeling trapped, having no hope or being in unbearable pain.

Behavior: New or increased episodic behavior, especially if related to a painful event, loss or change; increased use of alcohol or drugs; looking for a way to kill themselves, such as searching online for materials or means; acting recklessly; withdrawing from activities; isolating from family and friends; sleeping too much or too little; visiting or calling people to say goodbye; giving away prized possessions; and displaying aggression.

Mood: Displaying depression, anxiety, rage, irritability, humiliation or sudden calmness.

Beeson also explained that there are five levels of risk for suicide:

Nonexistent: No or few risk factors, no previous attempts and no suicidal behaviors.

Mild: A previous attempt but no other risk factors, or no previous attempts but demonstrating short-term, mild suicidal behaviors.

Moderate: A previous attempt with other notable risk factors, or no previous attempts but exhibiting ambivalent plans or preparation, suicidal desire or two other notable risk factors.

Severe: Previous attempt with two or more notable risk factors, or no previous attempts but having moderate or severe symptoms of resolved plans and preparation.

Extreme: Previous attempts with severe symptoms of resolved plans and preparations, or no previous attempts with severe symptoms of resolved plans and preparations and two or more other risk factors.

If a counselor has a client who is displaying suicidal risk factors, the first step is to ensure immediate safety, which in some cases may require hospitalization. Otherwise, the counselor and client can work to develop emergency plans that the client can follow if he or she is feeling suicidal, Beeson says.

It’s also important for counselors to establish a rapport with these clients and listen to their stories without judgment, he emphasizes. Counselors should then help clients manage their feelings by acknowledging their pain and encouraging them to use the session as a time to consider all options, including suicide, Beeson says.

Another critical factor is to guide clients in exploring alternatives to suicide by helping them envision future possibilities. Beeson says counselors should emphasize future plans by asking questions such as: How are you going to stay alive in the next week? Will you be back to see me next week? He adds that helpful behavioral strategies include drawing up a short-term positive action plan and using safety or wellness plans.

Beeson gives presentations on suicide frequently because he feels the topic is so important. “I just want to foster tough conversations about what we believe about suicide and the implications for practice,” he says. “I want people to live. That’s my goal. But I also believe in autonomy and the client’s right to choose. I think as we acknowledge that autonomy, we are better able to connect with people. I just think that one of the best ways to promote those types of interventions is to address what it is that we believe so that we can promote life-giving conversations. Then maybe we can promote that hope that the unattainable might just be attainable in some other direction.”

A playful approach to bullying prevention

Bullying prevention often focuses on punitive measures. The bully is identified, chastised and punished — with little or no consideration given to why the bullying occurred in the first place, says ACA member Ruth Ouzts Moore. And if counselors, teachers and other educators don’t address the underlying reasons, the likelihood of preventing bullying over the long term is low, she adds.

But how can counselors and educators learn the real reasons for bullying? Those who bully and those who are bullied often are too ashamed, scared or just plain angry to talk honestly about what is driving the bullying, Moore notes. That’s why she has come to believe that play, not punishment, is the best way to address and reduce bullying.

As a licensed professional counselor, counselor educator and part-time school counselor in the Savannah, Georgia, area, Moore has implemented this creative approach with young students and found it to be very effective. She described her experiences in a session at the ACA 2015 Conference.

Moore, an ACA member, began her presentation by clarifying the definition and different types of bullying. At its root, she said, bullying is an intentional, abusive act or attempt to inflict injury or discomfort on another person. She further explained that bullying can take the form of physical, verbal, relational or cyber abuse.

Bullying is fueled by the imbalance of power between the person doing the bullying and the person being bullied. Moore, a core faculty member in the mental health counseling graduate program at Walden University, noted that research suggests targets of bullying are at a disadvantage in this power differential for various reasons, which include:

  • Being perceived as different or weak and defenseless
  • Experiencing depression, anxiety or low self-esteem
  • Being less popular
  • Being perceived as annoying or attention seeking

Bullies, on the other hand, are generally students who are easily angered or frustrated, have family issues or are overly concerned with popularity.

For the targets of bullying, the gap between them and their tormentors must seem huge, but Moore notes that the bully and the bullied usually have similar backgrounds. For instance, children who come from abusive or violent backgrounds, grow up in neglectful environments in which there is little parental involvement or are caught in the middle of a high-conflict divorce face a higher likelihood of being bullied and bullying others, she says.

Bullying has serious and long-lasting effects on both the bully and the bullied, Moore points out. These effects include anxiety, low self-esteem, depression, suicidality, fear, mistrust, truancy, academic decline and nonsuicidal self-injury. In addition, the bully and the bullied are not the only ones affected. Bystanders, teachers, parents and siblings also suffer the consequences, directly or indirectly, she says.

Counselors face myriad challenges with both populations when working to address the issue, Moore says. Research has found that those who bully:

  • Often minimize or deny their aggressive acts and behaviors
  • Can be reluctant or resistant to disclose sensitive issues such as family violence or emotional problems that may be at the root of the bullying
  • Are sometimes repeating behavior that is intergenerational
  • Are often handled punitively and therefore may be distrustful of counselors

Similarly, research has found that those who are targets of bullying:

  • Often won’t tell anyone they are being bullied
  • May present in counseling with other issues such as depression, anxiety or school avoidance that may complicate or obscure the bullying issue
  • May have difficulty verbalizing their feelings
  • May not want to disclose bullying because they are ashamed and humiliated
  • May not disclose family problems that are at the root of or complicating the bullying

In her private practice, Moore has worked extensively with adolescents who bully or who have been bullied. She recently took on a school counseling position that allows her to address bullying with prekindergarten-age children through eighth-graders, both from a group and individual perspective. She notes that early education and intervention are the most effective means of preventing bullying.

Moore was hired specifically to address bullying at a private school that was having serious problems. Her goal was to help prevent bullying through identifying the sources of the problem, providing education and implementing active classroom strategies.

Moore presents weekly classroom sessions in which she combines educational sessions and activities in the form of games. She says the students enjoy the activities because they’re fun and provide a break from classroom work. The games also give Moore an opportunity to observe the classroom and identify the children who act out. She will often follow up by providing individual therapy to the most disruptive children.

Her activities focus on neutralizing bullying by increasing self-esteem and developing anger management skills. The self-esteem building activities include things such as a written quiz with 10 questions: 1) What’s good about you? 2) What’s good about you? 3) What’s good about you? And so on, with the same question repeated 10 times.

“It makes them laugh,” Moore says. “Kids often get stuck and can’t think about what’s good, so we’ll talk about how it’s hard to say good things about yourself because people will think you’re bragging, but it’s really important.”

In another game, Moore hands out Riesens caramels when students tell her the reasons or “Riesens” they like themselves.

During her presentation at the ACA Conference, Moore handed out balloons to audience members to demonstrate another activity she conducts for anger management. She asks the students to blow into the balloons to represent how stressful their day has been. The balloons end up being anywhere from just a tiny bit full to completely blown up.

“We talk about how amazing it is [to see] how quickly the balloons can fill up,” Moore says. She then goes on to talk with the students about how to moderate anger.

Another activity, “Bullying Bingo,” has helped students learn about the different types of bullying. Moore has also led students in activities to strengthen their sense of collaboration, such as by working together to build a peanut butter sandwich without looking at one another.

The activities seem to be having an effect. In the two years since Moore started working at the school, it has witnessed a huge decline in incidents of bullying.

Moore credits the creative approach for the results. She believes it works because the approach is nonthreatening, allows kids to express things they have trouble verbalizing and helps to build their confidence. On top of that, the activities are fun.

Moore encourages counselors to explore the creative approach when addressing issues of bullying. She also urges counselors who want to learn more to join the Association for Creativity in Counseling, a division of ACA for which Moore currently serves as secretary.

“Be open to new approaches,” she concludes.




Laurie Meyers is the senior writer for Counseling Today. Contact her at

Letters to the editor:

Confirming the benefits of emotional support animals

By Cynthia K. Chandler April 20, 2015

Have you received a telephone call of the following nature? “Can you certify my pet to be an emotional support animal?”

If you are a professional counselor, then the likelihood of you receiving such a request is on the rise. This is because word is spreading that the U.S. Department of Housing and Urban Development dog_1(HUD) recognizes the benefits of emotional support animals and provides regulations allowing them to live with an owner in designated nonpet housing (with a few exceptions) without requiring a pet deposit fee.

Exercising this right does not require that an animal be certified. What it does require is documentation that an individual has a legitimate need for an emotional support animal. The responsibility of providing this documentation lies with professional counselors and other mental health or health providers. In 2008, HUD stipulated that “persons who are seeking a reasonable accommodation for an emotional support animal may be required to provide documentation from a physician, psychiatrist, social worker or other mental health professional that the animal provides support that alleviates at least one of the identified symptoms or effects of the existing disability.”

Documentation and other considerations

A counselor who chooses to provide such documentation must do so in letter format on the counselor’s letterhead. The documentation should state that:

1) The named individual is under the counselor’s care

2) The individual has an emotional or psychiatric disability

3) The counselor recommends the individual have an emotional support animal to assist with the disability

The letter is provided directly to the individual who wants to have an emotional support animal live in the home. The individual can then choose with whom to share the letter.

In the documentation, the counselor does not label, define or describe the particular disability of the client. Rather, the counselor must state in general terms that the client has an emotional or psychiatric disability and that an emotional support animal can alleviate one or more of the symptoms or effects of the disability. Individuals need only provide proper documentation to a landlord to have a pet live with them as an emotional support animal in housing typically designated as excluding pets. The judicial system has interpreted this right to fair housing to additionally extend to individuals who wish to have emotional support animals live with them in college or university housing facilities, such as residence halls, dormitories or university-owned apartments.

The responsibility of providing documentation that would allow individuals to have an emotional support animal live with them should not be taken lightly. Based on the accompanying symptoms of a client’s emotional or psychiatric disability, a professional must determine whether living and engaging with an emotional support animal in the home might provide the client with some relief from the disability. To make this determination, it may be useful to have some understanding of how an animal may alleviate symptoms or effects of an emotional disability. Fortunately, there is research that provides guidance in this area.

In my 2012 book, Animal Assisted Therapy in Counseling, I reviewed several research studies on the psychophysiological and psychosocial benefits of positive social interaction with a pet, such as holding or stroking an animal. These benefits include calming and relaxing, lowering anxiety, alleviating loneliness, enhancing social engagement and interaction, normalizing heart rate and blood pressure, reducing pain, reducing stress, reducing depression and increasing pleasure. Based on the results of these studies, it is plausible that living with an emotional support animal may alleviate symptoms associated with a number of emotional and psychiatric disabilities. HUD states, “Emotional support animals by their very nature, and without training, may relieve depression and anxiety, and/or help reduce stress-induced pain in persons with certain medical conditions affected by stress.”

Another factor to consider in recommending that a client have an emotional support animal is whether the client has the ability and desire to properly care for an animal. Although human-animal interaction is known to assist people with developmental, emotional, social and behavioral disorders, it is important to assess whether any impairment is so severe that an animal would be neglected or harmed.

Dogs are the most common species to serve in the role of emotional support animals, but Section 504 of the Rehabilitation Act and HUD’s Fair Housing Act (FHAct) do not designate species restrictions for this role: “While dogs are the most common type of assistance animal, other animals can also be assistance animals.”

Emotional support animals vs. service animals

HUD legislation uses the broad term “assistance animals,” which is inclusive of both service animals and emotional support animals, when addressing the right to fair housing for individuals with these animals. In contrast, the fair housing rights and rights of access to other facilities included in the Americans with Disabilities Act addresses service animals only. To be clear, an emotional support animal is not the same as a service animal or a psychiatric service animal. Thus, emotional support animals do not have the same federal rights of access to facilities as do service animals. HUD provides the only current federal legislation that covers rights regarding emotional support animals, and this legislation is specific to allowing individuals to have animals live with them as emotional support in designated nonpet housing without financial penalty.

In 2013, HUD clarified that an emotional support animal is not merely a pet: “An assistance animal is not a pet. It is an animal that works, provides assistance or performs tasks for the benefit of a person with a disability, or provides emotional support that alleviates one or more identified symptoms or effects of a person’s disability.” However, HUD also stipulated that emotional support animals “do not need training to ameliorate the effects of a person’s mental and emotional disabilities.” Furthermore, “For purposes of reasonable accommodation requests, neither the FHAct nor Section 504 requires an assistance animal to be individually trained or certified.”

There are no qualification requirements for determining whether a specific pet is appropriate to serve as an emotional support animal. So, by default, an emotional support animal is basically a person’s pet that lives with that person and provides emotional support. HUD does stipulate that housing providers are not required to provide accommodations if an animal is destructive, poses a direct threat to the health and safety of others or interferes with the ability of a facility to perform its intended purpose. So, in practice, most people with proper documentation can have a pet live with them and serve in the role of emotional support animal as long as the animal is not destructive, disruptive or dangerous.


Because federal law does not require emotional support animals to be trained or certified, the potential exists for some of these animals to be unpredictable and cause harm. Until there is greater oversight regarding emotional support animals, I recommend that counselors avoid a chain of liability and not name a specific pet to serve as an emotional support animal. When providing documentation, refer only to the benefit of the individual having an emotional support animal, but do not name a specific animal. The decision concerning the specific pet to be designated as an emotional support animal should be made by the individual owner of the pet. It is not the responsibility of the counselor or other mental health provider to sanction the appropriateness of a particular pet to serve as an emotional support animal. That is not to say that counselors should avoid assisting individuals in the decision-making process regarding emotional support animals.

For instance, counselors can recommend that clients have their pets evaluated by a qualified evaluator before designating the pets to serve as emotional support animals. A standardized evaluation can often determine if an animal possesses the appropriate stamina and temperament to serve in this role.

Evaluation is important for health and safety reasons. Some animals may find the role of emotional support animal to be too stressful, and the emotional and physical health of the pet will be damaged. We must not overlook the welfare of the animals when considering whether they might provide emotional support for individuals with emotional and psychiatric disabilities. In addition, some pets can respond to stress with overprotective tendencies and aggression, putting members of the public at risk.

Many individuals desire to have their emotional support animals accompany them to pet-restricted facilities outside the home. Many businesses and institutions today are wrestling with how to make this happen while still maintaining the safety of those who may come in contact with these animals. It is my opinion, as a very experienced handler and animal team evaluator, that if individuals were to have their pets’ temperament evaluated by a qualified evaluator, both initially and periodically (say every two years), and provide current documentation that the animal had passed a standardized temperament evaluation, then they might be granted permission by a business or institution on a case-by-case basis to have their emotional support animal accompany them to places where pets are typically not allowed.

Animal temperament evaluations

Animal temperament evaluations assess the animal’s social attitude and behavior toward both people and a neutral test dog. In addition, the evaluation assesses the animal’s ability to walk politely on a leash, interact with a small crowd of people and respond to a variety of basic obedience commands by its handler. Failing a temperament evaluation would not interfere with the right of an individual to have the pet live in the home in the role of emotional support animal. Federal law protects this right. Qualified animal temperament evaluators can be found through national organizations such as the American Kennel Club (AKC) Canine Good Citizen (CGC) program and the national Pet Partners program.

The AKC website ( provides information about the CGC evaluation, which is best suited for the simple purpose of determining if a pet is well-behaved enough to be around the general public. However, it is designed solely to evaluate the temperament of dogs, not other species. The CGC evaluation is relatively inexpensive, takes about 30 minutes to complete and requires the handler to take the dog through a series of basic obedience commands. Local CGC evaluators can be found at many large pet stores that offer dog training for handlers or at community obedience training clubs. The Pet Partners organization offers evaluations for a number of different domestic animal species, but the investment in cost and effort is higher. This is because the intended purpose is to register Pet Partners teams that can provide services to the public as handler and therapy animal (note that a therapy animal is not the same as an emotional support animal). The Pet Partners registration requires a rigorous handler-team evaluation — for temperament, skills and aptitude — and requires the handler to complete a training that is available online or through an eight-hour, in-person workshop. The training includes learning about risk management and infection control procedures that are valuable to follow when a pet is engaging with the public. The Pet Partners website ( provides information on training and finding a local evaluator.

The animal temperament evaluation procedure may resolve a prominent ethical dilemma. If an emotional support animal can alleviate or assist with a person’s emotional or psychiatric disability at home, why shouldn’t the animal be allowed to serve this purpose outside of the home as well, such as in the classroom or a work environment? At the same time, because no oversight exists regarding behavioral requirements for emotional support animals, how do businesses and institutions protect the public from danger posed by a potentially unruly animal? Because there is no federal regulation that requires facilities other than housing to allow the presence of emotional support animals, then businesses and institutions can establish their own policies around this issue.

Requiring a standardized animal temperament evaluation may be a reasonable solution to thisDog_2 ethical quandary. The business or institution could provide a letter of access, for a designated period of time, to an individual accompanied by an emotional support animal if that person provides the institution with:

1) Official documentation from a professional counselor, or other mental health or health provider, designating the need for an emotional support animal (this could be the same documentation used for federal housing rights)

2) Proof that the animal passed a recently administered standardized temperament evaluation from a reputable source such as AKC or Pet Partners (the evaluation should have been completed within the past two years because appropriate animal temperament can deteriorate over time)


Perhaps the greatest source of confusion today is around the concept of emotional support animals. The general public may not be aware that emotional support animals are not the same as psychiatric service animals and therefore do not have all of the same federal rights to access facilities. Many people are unaware that current federal law does not require emotional support animals to be trained or evaluated. Thus, some emotional support animals with inappropriate temperament may pose a risk to the general public. Generally, the public does not realize that most emotional support animals are essentially a person’s pet serving in the role of emotional support.

I am an advocate for the idea of emotional support animals, but I firmly believe there should be greater oversight. This would include evaluation of the appropriateness of a pet to serve as an emotional support, taking into consideration both the prospective health and welfare of the animal and the health and welfare of the public, particularly if the animal is to accompany the individual to facilities outside the home. Current federal law clearly states that an emotional support animal does not have to be trained or certified to be allowed to live with a person, implying that the animal does not have to be evaluated either. But federal law does not make stipulations about access to facilities other than the home for emotional support animals. Thus, businesses and institutions are free to make policies that allow individuals to be accompanied by their emotional support animals, while also providing for the safety of the public.

Counselors can more effectively advocate for their clients if they understand federal regulations pertaining to emotional support animals. Additionally, this information is beneficial for protecting the general public from those who might misrepresent the role of their animal or the right for the animal to accompany them into pet-restricted areas. Unfortunately, profit opportunists exist who encourage such misrepresentation by selling (to anyone who is willing to pay) an official-looking — yet completely unofficial — vest for a pet to wear and a worthless “certification” document that may ultimately confuse the public about the legitimate role of the animal and the rights of the individual the animal is accompanying.

Federal advocacy for those with emotional or psychiatric disabilities, through recognition of the right to have an emotional support animal in the home, is a positive development in our society. Moreover, businesses and institutions that recognize the potential benefits of allowing an emotional support animal to accompany a person with a disability outside of the home reflects enhanced sensitivity to human welfare.

Animals are an excellent source of nurturance and companionship. Creating additional yet responsible opportunities for human-animal interaction enhances people’s lives. Movement toward greater integration of well-behaved animals into our daily lives at home, school and work is a reflection of enlightened social evolution.



Related reading: See Cynthia Chandler’s second Counseling Today article on this topic, “Is there an epidemic of emotional support animals?


Cynthia Chandler is a professor of counseling and director of the Consortium for Animal Assisted Therapy at the University of North Texas. She is author of the book Animal Assisted Therapy in Counseling (2012). Contact her at



Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Suicide prevention: There’s an app for that

By Bethany Bray April 15, 2015

A new smartphone app has been designed to put suicide prevention tools and resources at the app_1fingertips of medical and mental health professionals.

Practitioners who download the free Suicide Safe app will have access to case studies, training and data to help them recognize and address suicide risk in patients and clients.

The Substance Abuse and Mental Health Services Administration (SAMHSA) created the app specifically for primary care and behavioral health care providers. Designed as a learning tool, it connects practitioners to the most up-to-date, research-based resources to prevent suicide, according to SAMHSA.

Among the app’s resources is a primer on SAMHSA’s five-step suicide assessment method, as well as “conversation starters” practitioners can use to introduce the sensitive issue of suicide with clients.

For practitioners who need to refer clients, the app has a treatment locator that will find clinics and mental health professionals who are close to the location of the smartphone or tablet/iPad.

According to SAMHSA, nearly half of the people who die by suicide have seen a primary care provider in the month prior to their death, and 20 percent have seen a mental health provider in the month prior to their death.

“Suicide devastates lives throughout all parts of our nation, but it is a public health issue that is preventable. SAMHSA is working to provide people on the front lines with resources they need to save lives,” said SAMHSA Administrator Pamela S. Hyde as the app was released. “Suicide Safe is a major step forward in suicide prevention. The app gives behavioral and primary health care providers an essential and modern prevention tool at their fingertips to help address suicide risk with their patients.”

The app was launched last month to coincide with the 10-year anniversary of SAMHSA’s National Suicide Prevention Lifeline, 1-800-273-TALK. The 24-hour hotline has answered nearly 7 million calls since it launched in 2005.


app_2What apps do you find useful in your work as a counselor? Tell us and join the conversation in the comments section below.




Learn more about the Suicide Safe app at


Suicide Safe is free to download on Apple and Android phones; search for “SAMHSA” in your device’s app store.




SAMHSA’s Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) method:

1) Identify risk factors and note those factors that can be modified to reduce risk.

2) Identify protective factors and note those that can be enhanced.

3) Conduct suicide inquiry of suicidal thoughts, plans, behavior and intent.

4) Determine risk level and choose an appropriate intervention to address and reduce that risk.

5) Document your assessment of risk, rationale, intervention and follow-up with the client.





Bethany Bray is a staff writer for Counseling Today. Contact her at


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Assessing ‘ideal’ versus ‘real’ family characteristics with adolescents

By Brandon S. Ballantyne April 13, 2015

When working with adolescents in a group setting, it is important to provide opportunities to explore, evaluate and process the dynamics that occur within their homes. After all, eventually they will be faced with the dilemma of figuring out how to apply what they have learned in therapy to situations at home.

I have formulated a creative, psychoeducational task that allows adolescents to assess and explore the similarities and differences between their “ideals” and what really occurs within their unique and, at times, chaotic family relationships. I have broken this down into three simple categories. I ask the housedrawing_1adolescents to draw an illustration of a house. Inside the house are to be three distinct rooms with boundaries, because boundaries are healthy no matter how you slice that pie. The adolescents usually laugh at that analogy. Utilizing that humor, I then invite them to talk more about the boundaries at home.

I next ask them to label each of the three distinct rooms in the house. One section is labeled “Think,” another section is labeled “Do” and the last section is labeled “Say.”

I ask them to title their paper “Family Shoulds.” As a group, we discuss what the word “should” refers to. Typically, one group member will mention his or her impression of the word “should” as a reflection of a demand, expectation or wish. All of those definitions are acceptable for this task.

The idea is to have each group member write a list of three items for each category inside the house: three things they believe a family “should think,” three things they believe a family “should do” and three things they believe a family “should say.”

I have found that when I simplify group tasks in terms of “threes,” that the group flows more smoothly. For example, three rooms in the house and a list of three items for each of the three categories. I think this provides the task a sense of organization and predictability, thus increasing the group members’ level of trust and safety. This creates a less intimidating environment for each group member to talk about his or her family issues or other issues that may come up.

It is important to invite each group member to ask questions about the assignment. For example, I usually receive questions such as “What do you mean by things a family should say?” You might encourage the adolescents to write down specific things they believe a family should say to one another and then apply this to the other categories as well. For example, you might encourage the adolescents to write down three things they believe a family “should do together.” Or encourage them to write down a list of three things they believe a family “should think about one another.”

In the second component to this task, you instruct each group member to draw another outline of a house with the same three categories: think, say and do. Except this time, you ask the adolescents to write down their beliefs about their “Family Reals.” It is important to have a discussion about what you mean by the term “reals.” Usually, one group member will suggest that “reals” refers to facts or reality.

As the counselor, you can then take the focus of the group and place it on sharing ideas of “what actually goes on” from day to day in their families. Discuss how this is similar to or different from their beliefs about what a family “should” be doing, thinking, or saying.

This invites conversation about specific issues within their families that the adolescents want to address. You can also have a discussion about what “shoulds” are healthy versus what “should” are unhealthy. Finally, you can discuss which “shoulds” are realistic to address, identifying achievable, measurable steps to work toward at home.

As the adolescents listen to the other group members speaking about their family issues, they beginhousedrawing_2 to feel a sense of validation and belongingness. They cultivate a belief that “I am not alone.” As anyone who has studied Irvin Yalom likely knows, these three components are critical to the progress of individuals in group settings.

This task can also be used as a tool in family therapy sessions, serving as a less intimidating way to open the door to communication. It can be used to explore and address each family member’s expectations for others in the family unit.

It can be emotionally difficult for adolescents to talk directly about family issues. But as a counselor, I believe that if you can access adolescents’ creativity and provide a level of predictability, organization and safety, it will open the door to communication between you and your client. This can then be transferred to work with the family as a whole.

I believe this task creates opportunities for individual growth within the therapeutic relationship and opportunities for growth within the family system by reinforcing the difference between realistic and unrealistic expectations, discussion of problem-solving and implementation of communication skills.



Brandon S. Ballantyne is a licensed professional counselor, national certified counselor and certified clinical mental health counselor. Contact him at