Monthly Archives: January 2016

Nonprofit News: Avoiding bankruptcy

By “Doc Warren” Corson III January 25, 2016

Depositphotos_1500242_l-2015Nonprofit News is dedicated to examining issues that are of particular interest to clinicians working in nonprofit settings.

Among the biggest fears for directors of nonprofit programs are bankruptcy, closure, takeover and termination. These problems can be headed off by providing good leadership, making wise decisions and ensuring the overall health of your programming. In fact, many of the skills you often use in general therapy can be applied to managing your program. Exploring options, consulting with others and staying current on related literature and techniques can make the difference between a stagnant program and one that is vibrant, both in the clinical and administrative positions.

There is no single way to run a successful program, but the following items may help in the decision-making process.

Don’t jump into expansion: Many nonprofit programs find themselves getting into trouble as a result of an expansion that overreaches or is simply unsustainable.

In my consulting work, I have seen startup programs that were developing a “dream sequence” of services and an office space that was impossible to pay for. Some programs used all of their startup and maintenance money (the typically two- to three-years’ worth of money set aside to cover day-to-day costs while building a client base) just to rent and renovate their space. Although their new offices were beyond amazing and often offered state-of-the-art luxuries, this did little to help the programs, which soon shuttered their doors due to a lack of funds to cover costs while they established themselves.

I have also witnessed established nonprofit programs “go for broke” and gamble on new buildings, programs or other large infrastructure items. The thinking of these programs is that the improvements will lift them to a higher level and thus “pay for itself in no time.” Only later do they realize that the anticipated demand was not there.

Doing a little homework may have helped these programs realize that it takes time to become self-sustaining, even with limited overhead. By getting into massive debt, they all but assured themselves that they would fail. Market analysis is good, but it is little more than a guide and, in my opinion, should never be considered a guarantee. Sure, there is a demand in your area, but who says the community will embrace you? You may be much better off opening modestly and growing steadily as demand dictates rather than starting off at a full gallop only to find clients trickling in.

With the nonprofit program that I started, we opened our doors with a personal loan of $7,000. We were beyond humble: hand-me-down furniture, no fax machine and no advertising other than a press release. But we had a business model that called for modest and immediate reinvestment. Within weeks, we had the basic business equipment necessary, and within a year, our offices had been greatly improved, including the addition of durable furniture, most of which is still in use and in fine shape more than a decade later. (Helpful hint: Avoid trendy furniture and go for leather. It can be timeless and, although it costs more at purchase, it lasts far longer than fabric, which tends to look dingy after a few years of constant use).

Avoid loans and other financing when possible: Only use loans when absolutely necessary. Mortgages are often a part of life, but keep them to a minimum. It’s easy to get a loan for an addition when you have collateral, but this money needs to be repaid with interest. So unless you can afford to make that payment without counting on new revenue streams that may or may not materialize as part of the remodel, you could find yourself in dire straits. Sure, the model I am promoting may slow the pace of program growth, but it allows for real and sustained growth that also provides a healthier bottom line.

Look at trends (both emerging and waning) and know your audience: Knowing the state of your profession and your area can make a big difference. Look for things that may be at the verge of a great shift. Consider trying these things so long as they fit your overall mission. Also be prepared to scale back programs that may have hit their terminal velocity and are poised for reduced demand in the near future.

Consider your core client base: What do they want? What will they likely continue to want? What are they asking for that you currently lack?

In 2006, I saw a landscape that I thought might be on the verge of changing. For years, the focus had been on city life, high finance, and flashy clothes and lifestyle. I felt this trend was becoming played out to a large extent, at least in my part of the world. Always being a naturist at heart, I began exploring more earth- and nature-centered programming while staying true to my behaviorist mindset (I have an autographed picture of Albert Ellis in my main office). We explored ways to incorporate open space and nontraditional methods. Not all of our clients embraced the change, but we made it possible so that they were able to keep the traditional programming they loved as well. In time, we leased a local farm, and in short order we purchased the first chunk of it, as well as a few buildings. We steadily improved the land and buildings and built proper offices, without loans other than our mortgage. We continue to build steadily year after year and have experienced a large following and swell of support.

Here we are in 2016, and now you can Google “therapeutic farms” and find programs in many areas. This trend too will one day wane, but when it does, we should maintain well because of our lack of extended credit lines. Find your niche, but do not go too far into debt to pay for it.

Screen staff and maintain standards: Being good at what you do will enable you and your program to do well. But as you grow and need to add additional staff, maintaining standards can be difficult. Make sure to properly screen potential employees and thoroughly impart to them your core beliefs, philosophies and expectations for performance. Even this does not ensure quality care, but it will increase the likelihood of keeping turnover low. Many nonprofit programs suffer from hiring folks who turn from the program’s core philosophy and attempt to superimpose their own. Oversight and thorough supervision can help prevent this.

Remember your core mission: Mission creep can kill a program. Although there will be a need to expand services from time to time to meet the needs of your clients and to improve programming, it is important to regularly review your mission statement and core values to ensure that the changes meet the spirit (if not the actual letter) of the original intent. Mission statements can be altered when needed, but moving too far from your original mission can cause undue dilution of an otherwise solid program. Such dilution can confuse your client base and result in a reduction of referrals and other calls for services.

Build your board of directors: A board of directors is the steering wheel of any charity. Though not directly involved in day-to-day operations and activities, the board of directors is charged with guiding the charity in areas such as programming, financing, infrastructure and future development. When selecting potential board members, it is imperative to approach individuals who have a full understanding of the program’s core values, mission statement, psychology and mindset. By selecting members who “get” the charity, you are more likely to have a group of directors that is dedicated to your core values and to sustaining the overall feel and function of the programming.

Although each new year brings many challenges, with good fiscal sense and wise planning, there is little to fear and much to become excited about. The threat of bankruptcy need not be a specter hanging over your nonprofit.




Dr. Warren Corson III

Dr. Warren Corson III

“Doc Warren” Corson III is a counselor, educator, writer and the founder, developer, and clinical and executive director of Community Counseling Centers of Central CT Inc. ( and Pillwillop Therapeutic Farm ( Contact him at

The anxiety behind selective mutism

By Donna Mac January 19, 2016

Selective mutism is an anxiety disorder and currently one of the most misunderstood, underdiagnosed and undertreated conditions in mental health. When children with selective mutism feel expected or pressured to speak in social situations, they become terrified, resulting in their level of anxiety increasing significantly. By remaining silent, they decrease this anxiety level slightly and obtain some relief for themselves.

For these children, remaining silent serves as a defense mechanism or a maladapted solution to create a sense of safety within themselves. Their instincts guide them to believe that their best chance to maintain themselves at a baseline level of homeostasis comes with no action at all. photo-1451471016731-e963a8588be8Hence, their voices freeze, and they are silent. This provides them with temporary relief but, longitudinally, these children suffer in silence if not treated effectively.

It can be challenging to really understand the anxiety behind selective mutism, especially for the parents, teachers and clinicians working with these children. In trying to conceptualize the experience of selective mutism, I have an analogy to help clarify. When I go to the eye doctor for the glaucoma screening with the “puff of air in the eye test,” my eyes actually freeze shut. It’s clear that I physically know how to open my eyes, and despite what the eye doctor thinks, I actually want to keep my eyes open. But my anxiety takes over, and my fear physically closes my eyes. In this heightened state of anxiety, I have an inability to open my eyes.

It is the same for people with selective mutism. They know how to speak (although the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders has documented that approximately 20-40 percent of these individuals have a form of a speech and language delay). It’s also important to understand that most of these children desperately want to be able to speak to others, but they are unable to do so because their fear creates an inability to speak in that moment. In other words, they are not trying to be manipulative or defiant.

Is my fear of the eye test that administers a puff of air in my eye a realistic fear? No, of course not! The air is not going to hurt me. I logically know that, so it is an irrational fear that is disproportionate to the event. Most people have some irrational fears throughout their lives. This doesn’t mean that they have a full-blown anxiety disorder. However, when an irrational fear such as the fear of speaking to other human beings gets in the way of functioning — whether that involves social, academic or occupational functioning — it is a serious issue that needs to be addressed therapeutically (and possibly with medication in addition to therapy.)


Brain science

To further grasp what is going on in the anxious brain of selective mutism, it is crucial to understand a key autonomic mechanism in the brain. In 1915, Walter Cannon coined the term “fight or flight” to describe the instinctual, physiological reaction to fear. Fight or flight consisted of only two fear responses. More recently, clinicians have added a third fear response — to freeze. In his book Nerve: Poise Under Pressure, Serenity Under Stress and the Brave New Science of Fear and Cool, Taylor Clark explains that when a person freezes from this autonomic nervous system response, the person becomes an alarmed-looking human statue.

This is how children with selective mutism can appear. When children with selective mutism take no action, this means their mouths freeze, but sometimes their whole bodies are paralyzed by fear too. In our ancestors’ days in the wild, the brain’s autonomic freeze reaction may have been a valuable tool to save lives, but in cases of selective mutism in today’s society, this response makes lives worse. Aaron T. Beck, the developer of cognitive behavior therapy (CBT), states that evolution has long favored our anxious genes. This is because way back in our ancestors’ time, it was obviously better to experience “false positives” (false alarms) than “false negatives” (which miss the danger). Evolution’s favoring of anxious genes may explain why so many anxiety disorders are rampant today.

The autonomic system that was so beneficial to protecting and saving people’s lives many years ago has its roots in the amygdala of the brain. Research has shown that a person with anxiety experiences a hypertrophy in the volume of neurons in the amygdala, heightening fear responses and causing an overactive amygdala. The amygdala receives information from the sensory modalities. With selective mutism, this translates to people with selective mutism coming into contact with others through seeing or hearing them, which in turn activates their fear response. This means that once a person with selective mutism comes into contact with someone else, his or her autonomic nervous system — specifically the sympathetic nervous system — is activated with the fight, flight or freeze response, signifying extreme danger.

Once sensory information activates the amygdala, it triggers a response in the hypothalamus, which results in secretion of the adrenocorticotropic hormone from the pituitary gland. At about the same time, the adrenal gland is activated and releases the neurotransmitter epinephrine (adrenaline). All of this produces the stress hormone cortisol, which creates an acute boost of energy. Catecholamine hormones such as adrenaline (epinephrine) or noradrenaline (norepinephrine) facilitate immediate physical reactions and prepare us for danger. In response, the body instinctively fights, flees or freezes.

The body cannot physically stay in such a heightened state of arousal for long periods of time, so the parasympathetic nervous system then activates the release of acetylcholine, the neurotransmitter that brings the body back to homeostasis after the fight, flight or freeze response. It is important to understand that the definition of “homeostasis” is different for a person with any anxiety disorder than it is for a person without an anxiety disorder. At a baseline level, research shows that people with an anxiety disorder will still be in a more-heightened state of anxiety than will a person without an anxiety disorder. This means that even at baseline level, children with selective mutism will most likely still not be able to speak to others outside of their immediate families without having been through treatment.


Treating selective mutism

How can children with selective mutism’s severe fear response be better managed so that they can more effectively function at school and in social situations in the community?

First, there needs to be antecedent management to adjust the environment and the triggers to the child’s anxiety. Antecedent management can be accomplished using concepts from Sheila Eyberg’s parent-child interaction therapy (PCIT). This includes incorporating her concepts of child-directed interaction and PRIDE skills (praise, reflect, imitate, describe and enjoyment) both at school and in community settings.

PCIT can also be used in combination with a gradual exposure model in which B.F. Skinner’s operant conditioning is implemented. However, it is important to remember that operant conditioning is effective only when the environmental expectations of the child match the skills the child is capable of. How does a child become capable? This is when the psychoeducational skills from Beck’s CBT and mindfulness from Marsha Linehan’s dialectical behavior therapy can also be beneficial.

It is important to note that any and all of these techniques can be tried with many different anxiety disorders. As a clinician, I have tried all of these techniques in the therapeutic day school in which I work with students with generalized anxiety disorder, social anxiety disorder, school anxiety (school refusal), posttraumatic stress disorder and obsessive-compulsive disorder. Many of these techniques, originated by well-known clinicians, have been researched to show statistically significant results in managing anxiety in many anxiety disorders.

Once these children’s environments are controlled with antecedent management, their behaviors are shaped with successive approximations, working toward an incentive in which they are positively reinforced through operant conditioning and they have the psychoeducational skills to reduce their anxiety. When this happens, they will be more likely to be able to speak.

Many times, a foundation of intensive treatment for selective mutism is beneficial in getting a head start with this type of treatment because of the combination of interventions. Outpatient intensive treatment typically equates to 30 hours in one week with clinicians specializing in selective mutism. The skills practiced during the 30 hours of intensive treatment seem to hold their gains better than they do when acquired and practiced one hour per week in therapy. Imagine getting a 29-week head start and saving 29 weeks of a child’s life. Multiple intensive treatment centers exist across the country, many of which are based on a “day camp” model running roughly six hours per day for one week at a time. The child is typically placed with a group of children based on age level, and each child has a one-on-one clinician who rotates throughout the week.

Once the foundation of these skills has been built in an intensive program, the skills can be generalized into the child’s school environment and social situations within the community. Clinicians from the intensive treatment programs for selective mutism can then help train the parents, the child’s regular therapist and the child’s school staff members on how to best utilize antecedent management with the child, while also teaching them how to help the child manage anxiety so she or he can continue to be verbal with other people outside of the intensive programming setting.





Donna Mac is a licensed clinical processional counselor conducting psychotherapy in a therapeutic day school, treating children diagnosed with many mental health conditions. In addition, she is the mother of identical twin daughters, age 6, diagnosed with selective mutism, apraxia of speech, attention-deficit/hyperactivity disorder and a mood disorder. Her latest book is titled Suffering in Silence: Breaking Through Selective Mutism. Visit her website at for more information on selective mutism.


More from Donna Mac at Counseling Today:

Diagnosing ADHD in toddlers

The connection between ADHD, speech delays, motor skill delays, sensory processing disorders and sleep issues



CDC reports drug overdose deaths at ‘epidemic’ levels

By Bethany Bray January 14, 2016

More Americans died from drug overdoses in 2014 than in any previous year on record.

The 2014 statistics, released last month, indicate that U.S. drug overdose deaths have reached an epidemic level, according to the U.S. Centers for Disease Control and Prevention (CDC).

In 2014, 47,055 drug overdose deaths occurred across the U.S., 61 percent of which involved some type of opioid, including heroin. States with the highest rates of drug overdose deaths in 2014 include West Virginia (35.5 deaths per 100,000), New Mexico (27.3), New Hampshire (26.2), Kentucky (24.7) and Ohio (24.6).

Deaths from opioid overdoses, which include prescription painkillers as well as heroin, increased 14 percent from 2013 to 2014. Heroin overdose deaths rose by 26 percent. The CDC reports that the rate of overall opioid overdoses in the United States has tripled since 2000.

Overall, drug overdose deaths increased from 2013 to 2014 in both men and women, in non-Hispanic whites and blacks, and across all adult age groups, according to the CDC’s Morbidity and Mortality Weekly Report.

“The sharp increase in deaths involving synthetic opioids, other than methadone, in 2014 coincided with law enforcement reports of increased availability of illicitly manufactured fentanyl, a synthetic opioid; however, illicitly manufactured fentanyl cannot be distinguished from prescription fentanyl in death certificate data,” writes the CDC. “These findings indicate that the opioid overdose epidemic is worsening. There is a need for continued action to prevent opioid abuse, dependence and death, improve treatment capacity for opioid use disorders and reduce the supply of illicit opioids, particularly heroin and illicit fentanyl.”


Graphic via the U.S. Centers for Disease Control and Prevention.

Graphic via the U.S. Centers for Disease Control and Prevention.





For more details, and a state-by-state breakdown of data, see the CDC’s Morbidity and Mortality Weekly Report.


For counselor resources on addiction, visit the International Association of Addictions and Offender Counselors, a division of the American Counseling Association, at


Related reading: See a review of the book From the Needle to the Grave: My Sister’s Journey With Heroin Addiction as Told Through Her Journals at CT Online:





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


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook:


Behind the Book: Counseling Older People: Opportunities and Challenges

By Bethany Bray January 11, 2016

Older adults are the fastest-growing segment of the U.S. population. The number of people age 65 and older is expected to nearly double by the year 2050.

From helping with family dynamics and end-of-life issues to working on a client’s coping and communication skills after hearing loss, counselors are uniquely skilled to help the older adult Branding-Box-Older-Peoplepopulation, says Charlene Kampfe, a retired counseling professor, nationally certified gerontological counselor and national certified rehabilitation counselor.

“With the growth of the older population, we counselors will have the exciting opportunity to carve a place for our profession in those systems that serve older people,” Kampfe writes in the preface of her book, Counseling Older People: Opportunities and Challenges. “Although some counselors may not have worked with older consumers in the past, they already have many of the skills necessary to do so. Counselors understand and support the concept of empowerment. They know how to provide a safe, respectful and challenging environment in which individuals can explore their thoughts, feelings and behaviors. They have also been trained to be good listeners, advocates, problem solvers and case managers.”



Q+A with Charlene M. Kampfe


In your book, I notice that you use the phrase “older population” instead of other terms (senior citizen, geriatric, elder, etc.) Why?

An excellent question. One of the primary reasons that I chose to use the phrase “older population” is that some of the other terms seem to have taken on a negative connotation. “Senior citizens,” “geriatric” and even the word “elder” may now be terms that have been viewed by our current society with a negative perspective — e.g., age prejudice. Another phrase that I use is “people who are older” rather than older people. I did this in order to focus first on the person/s and then on one of their qualities — i.e., people who are older, people with disabilities, people who have visual impairment, people who are age 65 or older, etc.).


From your perspective, how are counselors a good fit to work with the aging/older population?

I could say so much about this, but will keep this answer at a minimum. Throughout my book, I describe the reasons that counselors are a good fit for working with the older population. Counselors have the ability to listen — to really listen. One of the issues often faced by older people in our current society is that they are not listened to. Therefore, the listening skills of the counselor are vital to this population.

Counselors also have the ability to empower their clients. By empowerment, I do not mean they give the power to the person; I mean they recognize and acknowledge the power of the person they are counseling. In our current society, many older people are no longer given the opportunity for choice and decisions about their own or their families’ lives. Therefore, the counselor’s ability to encourage client power is vital for this population.

Furthermore, counselors have the ability to advocate, both individually and systemically, for clients. Advocacy is vital for people who are older because many of the systems that serve them do not serve them well or are disempowering. Counselors have the ability to do creative problem solving. Therefore, they can support consumers as they negotiate the many transitions and issues they face as they age. Counselors know that each person is unique and does not fit a mold. Counselors can use this understanding to avoid putting all older people into a single category with the same skills, wants, needs, issues, etc.


In your book’s preface, you say the systems that serve older people often leave seniors “disempowered.” Can you elaborate? How could counselors help in this area?

Many of the systems or service providers that serve older people assume that all older people are the same or similar. They may assume that older people are no longer able to make their own decisions. It is likely that children or service providers who think they are “helping” older people are actually taking away the opportunity to make decisions for themselves, doing things for them that they can do, ignoring their desires or disempowering them.

Counselors can help by counseling family members to … recognize how their behaviors may be disempowering and to find new ways of interacting with their older family members or friends, advocating for systemic change within institutions that are disempowering, modeling behaviors that are empowering rather than disempowering and serving on boards of or acting as consultants to service providers. Counselors can act as staff trainers to challenge disempowering attitudes and practices. See my book for a reference to a training package that is available to counselors.


What are some main takeaways you want counselors of all types and specialties to know about working with the older population, especially considering this population is one of the fastest-growing demographics in the U.S.?

One important point is that this group is not homogeneous. Some scholars have suggested that it is the most diverse of all groups today. Simply by virtue of the definition of “older,” this group can span 40-plus years — 65 to 105 or older. Each generation — those who are age 65 versus those who are 75, 85, 95, 100 or 105 — has experienced unique life experiences based on the year they were born. Furthermore, within the older population, there is diversity in race, culture, location of birth, education, health status, life experiences, family perspectives, mental status, etc. Counselors can, therefore, not lump this group into one category. Each person will be unique, and that uniqueness should be recognized and honored.


What would you want a newly graduated counselor to know about working with the older population? What might not have been covered in their studies?

New counselors can use all the counseling strategies they have learned in their graduate studies. Perhaps the most important things that they will now need to do are:

1) Examine their own attitudes toward aging and older people. This is discussed in detail in my book, [and] exercises to challenge one’s own attitudes toward aging are included.

2) Learn about the multitude of transitions that older people may be experiencing, and learn ways to support these people as they make these transitions. Learn problem-focused counseling skills, and learn about the specific transitions that older people may experience.

3) Learn about the various systems that serve older people — e.g., Medicare, Social Security, nursing homes and other residential options, health care systems, mental health programs, recreation programs, social service programs, etc. Know the ways these systems can be of assistance to older people, and know the problems associated with these systems. Keep current about changes in such systems. Learn about the legal issues associated with being old. In nearly every chapter of my book, I provide resources for each topic. These are very valuable resources that can be of great help to counselors and the consumers they serve.

4) Recognize that the older population is one of the most diverse populations in the United States and that older people cannot be placed in any specific category. Learn about the various issues faced by people from specific cultures.

5) Learn how to advocate for the older population and for individuals who are older. This can be systemic advocacy and individual advocacy.

6) Learn about the issues of people who are caregivers to older people. Learn how to work with these people in order to help them with their own personal issues. Learn how to show caregivers the importance of dignity versus dehumanization and personal choice of the people they serve.


From your perspective, how can the counseling profession as a whole become more involved in the care of the older population?

The counseling profession, as a whole, can be especially watchful of legislation that is being considered regarding the older population and become activists when the legislation seems to create negative issues for that population.

The counseling profession, as a whole, can:

  • Focus on its own attitudes toward aging
  • Consider the concepts of positive aging
  • Advocate for better and more empowering living conditions for older people
  • Advocate for more positive societal and service workers’ attitudes toward aging
  • Advocate for employment opportunities for older people
  • Reinstate the national gerontological counselor certification (a specialty the National Board for Certified Counselors retired in 1999)
  • Develop program guidelines for gerontological counseling specialties


The book as originally written was almost twice as long as the resultant book. There is so much for people to know. I would suggest taking a class in gerontology, aging, etc., in order to get more details. Also, counselors can use the many resources that are listed in my book to learn more about each specific topic.


What inspired you to write this book?

I was blessed as a child and young woman to know and love three of my great-grandparents. I was also very fortunate to have and to know my four grandparents. All of them taught me many important life lessons from their various perspectives. Likewise, my parents and other family members were wonderful mentors and supporters. In other words, I learned the value of people who were older as a young person.

Over the years, I began to find that one of my professional foci was aging. I was influenced by various people who were counselor educators and leaders who were interested in the older NursingHomepopulation — e.g., Mae Smith, Jane Myers — and who taught me much about attitudes toward aging and about specific issues associated with aging. These mentors had great influence on my path.

Over the past 30 years, I have engaged in a great deal of research and writing about the older population. I also became heavily involved in the Association for Adult Development and Aging (AADA), a division of the American Counseling Association. As a member of AADA, I served as president, chair of many committees and as an ACA Governing Council representative of this wonderful, family-like professional organization.

Another inspiration has been my lifelong work as a rehabilitation counselor and rehabilitation educator. I have been guided by rehabilitation principles such as dignity versus dehumanization, personal power, personal choice versus being told what to do, appropriate language when speaking of and to different populations — i.e., person-first language — advocacy for and by consumers themselves, respect for consumers, etc.

In summary then, my book Counseling Older People: Opportunities and Challenges, is the culmination of my personal and professional interest in people who are older, the issues they face, the strengths they may display and the role of counselors in their lives. At my own retirement, I desired to continue to serve the counseling community and the aging community by writing this book. It has been a fantastic journey.





Counseling Older People: Opportunities and Challenges is available from the American Counseling Association bookstore at or by calling 800-422-2648 x 222.





About the author

Charlene M. Kampfe is professor emeritus of rehabilitation counseling at the University of Arizona, Tucson, a nationally certified gerontological counselor and national certified rehabilitation counselor. She is a past representative to the American Counseling Association Governing Council and has held leadership positions in two ACA divisions: the Association for Adult Development and Aging (past president) and the American Rehabilitation Counseling Association.

She is also a member of the International Association for Creative Dance and dances regularly at the Tucson Creative Dance Center.




Related reading

For more on counseling and the older population, see Counseling Today’s 2014 cover story, “Ages and stages





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


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook:

Why failing the NCMHCE felt so good

By Alyson Carr January 6, 2016

The day I failed the National Clinical Mental Health Counseling Examination (NCMHCE) was the best day of my life. I didn’t know this on the day it happened, of course, because my judgment was clouded by lots of tears, snot and defeat.

You know those classmates or colleagues who seem to easily earn A’s on tests without having to put a whole lot of energy into studying? Yeah, me too, and I’m not one of those people. I’ve always done ExamStudypretty well in school, but I’ve had to work really hard to earn high grades.

Having insight into your strengths and weaknesses as a learner is half the battle when it comes to preparing for examinations because once you have identified your shortcomings, you can target those areas and try to bridge the knowledge or study skill gaps and (hopefully) successfully conquer whatever test is in front of you. After years of being both a student and an educator, I know my learning style and how to target my weaknesses — or so I thought until I became a miserable failure, hyperventilating on the phone to my mother like a child as I broke the news that I hadn’t passed the NCMHCE.

How did I prepare to fail my test, you ask? Diligently. I did a lot of preparation. I worked really hard for that big “F.” I consulted with colleagues who had successfully passed their exams about the materials they had used to prepare, I studied every day for three months, my husband quizzed me in the mornings before work and I performed really well on the practice exams before I went into the real deal.

I was ready. I was ready to pass something for which I had worked so hard. I was ready to finally see the letters LMHC (licensed mental health counselor) after my name. I was ready to reach more people in need. I was ready to experience this rite of passage. Or so I thought until I had to cancel the celebratory dinner planned for after the exam because I obviously wasn’t going to celebrate being such a pathetic loser.

For a while, I thought I failed the exam because I had a panic attack. Sometimes I still like to tell myself that was it. It couldn’t possibly be that I was unprepared or didn’t possess the knowledge required to independently practice — no way, it was just panic, and it was totally out of my control.

In my defense, I did have a panic attack. I saw that I was getting many answers wrong in a row, and I was certain it meant failure. Class, what do we know about self-fulfilling prophecies? If we tell ourselves we are going to fail, we likely will, and that’s exactly what I did.

However, this panic wasn’t reduced to feeling like I was going to have a heart attack because of failing alone. This panic was more dynamic and was perpetuated by realizing the truth — I wasn’t ready.

If I had been more prepared, I would have been able to recover from losing all of those points. If I had been more prepared, I would have had a larger margin for errors. I panicked because any sensible counselor would have entertained the same question I did: If I’m not prepared to pass this exam, am I really the best person to be in a position of counseling clients who deserve the highest quality of care? Pondering this question caused me more emotional distress than failing the exam ever could. I bet a lot of registered interns who have failed ask themselves the same thing.


Feeling grateful for failure

On the day I failed the NCMHCE, I experienced a spectrum of emotions during a 24-hour period. First, I was selfishly discouraged and wondered, “Why me?” Then I was embarrassed and wanted to save face, so I thought about not telling anyone that I had even taken the exam. But I realized that I can’t keep my mouth shut about anything for longer than five seconds, so everyone who encountered me over the prior three months was anticipating my good news about passing. Next, I was mad. I was angry with anyone who had passed a test ever in their lives. I was especially angry with colleagues who seemed to not study at all but managed to pass the exam on their first attempt.

After I got through all of these confusing emotions, I started trying to make sense of things by asking questions such as the one I mentioned previously: “Am I, The Failure, truly delivering the best care to my clients?” By the way, I still don’t know what the answer was to this question at the time. In hindsight, I realize the important thing was that I was asking it in the first place.

Reflecting on this question and client welfare was what motivated me to make a decision. I decided I would throw myself a pity party for one day, then move on with my life and make passing this exam my top priority.

Looking back, I can see that passing the exam wasn’t necessarily my goal. Instead, my goal was to pass and feel like I should have passed. If I had passed on my first attempt, I can say with complete confidence that it would have been the result of pure luck. My clients would not have been getting the caliber of care they deserved because I would have been a licensed professional with a false sense of confidence about my abilities. Taking this into consideration, I became grateful for being a failure because, in my case, being a failure meant not being a phony.

So, I woke up the next day and stuck to my guns about my renewed perspective. I wasn’t going to rehash the pain and suffering associated with failing because I was glad for it. What was done was done, and if a client were in a similar situation, I would pull out every tool in my Counselor Tool Belt to help lead that person to a place where he or she could see the silver lining in all of this.

I wanted to lead by example. I told everyone I failed, including my clients. I wanted them to know that I was human too. I also felt like this piece of professional disclosure was important coming from a registered intern (no, I don’t believe it is unethical if you choose to keep this sort of information to yourself unless you have a contract with an employer outlining terms and expectations in the event you fail).

So, everyone knew I had failed, but more importantly, everyone knew I was determined to overcome the defeat, and that was very empowering. The support from friends, family and colleagues was so warm and loving. And as a result of talking openly about my failure, I learned about others’ experiences with not passing the NCMHCE. Collectively, we embraced emotionally, and I was reminded once again why being in this profession is such a tremendous gift.


The waiting game

Those of us who fail the NCMHCE are forced to sit around for three months sulking in our misery before we are eligible to retake the exam and ultimately amend our stories of the journey toward licensure. I spent those three months confronting the reality that I needed to be more prepared for the test. I needed to feel more prepared for the purposes of alleviating my anxiety, both while studying and so I could manage my panic during my second attempt at the hardest exam I’d ever taken.

I spent more time with the Diagnostic and Statistical Manual of Mental Disorders — a task I don’t think I executed well the first time. I developed some systematic ways of measuring if I was improving and how. I turned preparing for the exam into a second full-time job. I owed this to myself and to the clients who meant so much to me. As it turns out, I also owed this to the baby growing in my belly.

I took my exam for the second time exactly three months after failing the initial attempt. I walked into that testing room committed to not standing in my own way again and prepared to give my second attempt everything I had. I went to the bathroom in between every simulation because taking breaks and going slow is really helpful in terms of managing test anxiety. Going to the bathroom often is also very helpful to a pregnant lady who has a fetus doing back handsprings on her bladder.

When I went into the bathroom, I prayed to every god I knew. I practiced deep breathing. I used imagery techniques to visualize peaceful and tranquil landscapes.

And I talked to my unborn baby: “I want to set an example for you, little one. One day, I want to be able to tell you that I did it right this time. I have already learned so much from you, and you aren’t even here yet, but if there is anything I hope you can learn from me it’s that success tastes so much sweeter when you know you’ve truly earned it. There will be times in your life when you will fail. The experience of picking yourself up afterward will vary depending on the failure. But it’s not the getting knocked down that defines who you are; it’s how you define failure and success and how you conceptualize the complexity of personal growth and development. I pray to this mass-produced picture of a forest in this H&R Block bathroom with customers yelling at accountants about their taxes on the other side of this door that I can give you the same strength you are giving me right now.” I truly used every channel I could to communicate to myself that I could do it this time.


Moment of truth

When I walked out of the testing room through the lobby four hours later to get my results, I saw my husband still waiting for me in the parking lot. He had a good view of the facility from his parking spot, so he had seen me come out of the testing room and walk through the lobby 10 times previously to use the restroom. Each time he had wondered if this was the time. Was I done? Was this it? Had I just drank too much water, or was I done failing again? Had I passed? Was today the day I was going to finally get to drink my celebratory sparkling apple juice?

I walked over to the proctor to get my results. I learned the first time how this process worked from the way the proctor turned my results sheet over and gave me that look of “poor you.” This time, he grabbed my score sheet from the printer and, before handing it to me, looked at it and said, “Wow, great job.”

Alyson Carr proudly shows her NCMHCE results.

Alyson Carr proudly shows her NCMHCE results.

I lunged at this complete stranger, hugged him tightly, thanked him for being the bearer of such relieving news and bolted into the arms of my husband outside, who cried tears of joy and accomplishment with me. I didn’t get the sparkling apple juice, but I did get an ice cream sundae from Dairy Queen. It was the most delicious treat I’ve ever consumed, not because it was exceptionally good ice cream or because I was so hungry that even tire rubber would have tasted incredible at that moment, but because I had achieved something great. Passing was obviously a desirable outcome, but this victory was not about passing — it was about overcoming an obstacle.


A new sense of purpose

As a result of my personal failure, I’ve been inspired and made a career out of helping others pass the NCMHCE. In addition, I’ve dedicated all of my doctoral research to examining the impact of test anxiety on academic performance as it relates to this exam.

The footnotes are this. There are generally two types of highly anxious test takers. The first type fails tests because of test anxiety alone (they have problems retrieving information in the testing situation). The second type fails tests because of test anxiety and poor study skills (they have problems both with encoding the information when they are studying and retrieving the information in the testing situation). I recommend looking into Moshe Naveh-Benjamin’s numerous studies exploring the variables that contribute to the relationship between test anxiety and academic performance if you’re interested in this kind of stuff.

In any case, the bottom line for me is that my failure helped me find myself and a career path that truly makes me happy. Let’s be serious, how many people can say that? If you’re reading this, you’re probably a counselor, so you know from your clients that the answer is “not too many.” Before I became a failure, I was treading water trying to figure out what I was passionate about. For me, failing turned out to be my one-way ticket to a fulfilling job.


Overcoming personal barriers

Everyone has a different demon to fight when it comes to attempting the NCMHCE. For me, I needed to do some serious reflection on what this exam represented to me before I could be successful. An additional distraction during the time I was studying for my second attempt was a high-risk pregnancy and the associated fear that comes with that type of a personal speed bump.

After ending an abusive 25-year marriage, Danielle pursued her master’s degree in mental health counseling when she was 57 years old. Getting back into the swing of studying wasn’t easy for her. She reached out to me after failing the NCMHCE five times and passed on her sixth attempt. She said, “I don’t care how many times it takes me to pass this, I want it, and I will get it.”

Gene’s boss told him that he would be terminated at the end of the month if he didn’t pass on his third attempt. This presented incredible stressors for Gee as the breadwinner for a family of five.

Passing the exam for Connie on her third time meant that she could finally provide services to mothers who had lost young children. This was important to her because her entire career had been inspired by the loss of her 3-year-old daughter in a drowning accident.

Jack was waiting to propose to his girlfriend until after he passed the NCMHCE because he wanted to provide for her and felt like he couldn’t give her the life she wanted until he was licensed.

Jessica became unemployed as a result of failing her exam; Alex gave up going to her kids’ soccer games for three months; George balanced a 60-hour workweek so he could afford study materials while preparing for his fourth attempt.

We all have incredible sources of inspiration, but we also have legitimate barriers (as well as irrelevant excuses) that can stand in the way of our success. With that said, however, we are counselors. We have been there for clients who are up against obstacles we can barely wrap our heads around. We struggle, we suffer and we weep for the clients who have experienced devastation. We are trained to provide support and guidance to those going through struggles. We help people make meaning out of their tragedies, and then we move on to the next thing.

Epictetus said, “When something happens, the only thing in your power is your attitude toward it; you can either accept it or resent it.” The very foundation of cognitive behavior theory is rooted in the idea that it’s not the event itself that causes emotional distress but the meaning we assign to the event. It is easier to look back at this journey once you are at the end of it with a positive attitude, but it is during the treacherous climb to the summit that the valuable internal work takes place. This parallels the counseling process.

You may fail the NCMHCE. In fact, statistically, failing is likely (40-45 percent of people do). Or you may pass. You might not even define scores on a test like this as an effective evaluative tool to measure success. But regardless of your interpretation of these concepts, don’t forget that you are the one invited into the lives of people during their most challenging battles. You are the person who helps them suit up, fight and win.

We should want for ourselves what we want for our clients — the ability to turn our most difficult experiences into an opportunity for self-discovery.




Alyson Carr is a licensed mental health counselor with a doctorate in counselor education from the University of South Florida. Contact her through her website at




Related reading: See Alyson Carr’s article “Preparing for the NCMHCE” at Counseling Today online: