Monthly Archives: April 2018

Using nature as a therapeutic partner

By Lindsey Phillips April 26, 2018

In 2013, officials in Melbourne, Australia, assigned the city’s trees ID numbers and email addresses to make it easier for citizens to report problems such as fallen limbs and unwieldy branches. However, Melburnians used the email-a-tree-service for another purpose: to talk directly to the trees. They sent emails to the trees expressing their love and appreciation, and they also treated the trees as friends, discussing topics such as school tests, tree biology, construction work and politics.

This unexpected exchange underscores the human desire to reconnect with nature, yet urbanization and technology often distance people from the natural world. “Nowadays, we’re spending close to 90 percent of our time indoors,” says Megan Delaney, an assistant professor in the Department of Professional Counseling at Monmouth University in New Jersey. “This is a major shift in how we utilize our time. And some of that has to do with how we live. We are in our cars. We are in our offices. … We don’t walk anywhere anymore.”

This disconnect comes at a cost because nature plays a role in our mental health. In fact, a prescription of nature may be just what the counselor ordered. Research suggests a possible link between increases in obesity, diabetes and attention-deficit/hyperactivity disorder (ADHD) symptoms and a lack of outside time, says Patricia Hasbach, a licensed professional counselor and clinical psychotherapist with a private practice in Oregon.

Delaney, who has a small private practice in New Jersey and recorded a podcast on ecotherapy this past year for The Thoughtful Counselor (, says research also suggests a connection between the increase in anxiety and depression in children and their disconnection from nature. “There’s been a loss of this free play,” Delaney argues. “If [children] go outside at all, it’s controlled.”

Nature isn’t a panacea, but even going outside for as little as five minutes a day will provide a boost to well-being, Delaney contends. In addition, exposure to nature can help improve relationship skills, reduce stress and aggression, help with the ability to focus, reduce symptoms of ADHD, improve impulse control and even improve fetal growth and birth rate, she says.

Unwilding ecotherapy

Despite the positive benefits, the idea of incorporating nature into counseling often overwhelms clinicians and clients because they assume it means wholeheartedly embracing the “wild” — packing up their belongings and taking a solo hike on the Pacific Crest Trail (à la Cheryl Strayed) to “find themselves.” For others, the very thought of “wilderness” or “nature” raises fears of the possible dangers, ranging from bug bites and sunburn to life-threatening injuries and encounters with dangerous animals.

The word ecotherapy often evokes a common myth of being fully immersed in the natural world, living and sleeping on the ground, says Delaney, an American Counseling Association member whose book Nature Is Nurture: Counseling and the Natural World is under contract. “That’s not what [ecotherapy] is about,” she argues. “It’s about our reconnection to our relationship with nature in whatever form that feels right for you. It could be a window box with your tomato plants. … I think that dispelling that myth is important.”

Ryan Reese, an assistant professor of counseling at Oregon State University-Cascades, agrees that a misconception often surrounds the idea of integrating nature into therapy. “[Clinicians] don’t have to take clients out into a wilderness setting in order for it to be EcoWellness or ecotherapy,” he says. “It can be at a park or walking on a trail that’s flat.”

Thus, expanding counselors’ and clients’ definition of nature becomes key, Reese argues. “We all are going to define nature in our own sociocultural, political context. How I define nature is probably going to be different than [for] somebody who grew up in downtown Manhattan.”

Reese, who has a private practice in Oregon, finds that broadly defining nature is beneficial, especially for clients who lack access to more traditional natural settings such as rivers, woods and mountains. To achieve this, he says, counselors might work with clients to expand their assumptions about nature by asking if it could include a local park, their backyards or even a view of trees from an office window.

When Delaney presented at the ACA 2017 Conference & Expo in San Francisco on wellness and nature, she was shocked that approximately 150 people attended. At the end of the presentation, several clinicians approached Delaney and stated they were already conducting nature-based counseling but wondered if they were doing it correctly. To which she responded, “If it feels good, you are probably doing it right.”

“People are doing [ecotherapy] intuitively and don’t know the theory behind it,” she continues. “They probably are taking their clients outside. They probably are prescribing nature. They’re probably doing things with kids in natural spaces. Maybe they bring their dogs into the office. … When they read the science and research behind it and the theory … [they] get it.”

There is growing interest in ecotherapy among counselors and, thus, more options for training, says Hasbach, an ACA member who teaches ecotherapy at Lewis & Clark College in Oregon. Her continuing education course, “Prescribing Nature: Incorporating Ecotherapy Methods Into Your Clinical Practice,” quickly fills up with professional counselors and therapists from all over the country.

Reese, an ACA member who occasionally offers a one-day workshop on interventions and ethics for integrating the natural world into therapy, recommends that counselors take training courses to help them consider things they might not think about otherwise. For example, he has noticed that his boundaries can change when he is outdoors with a client. Because he feels calm and relaxed, he is more susceptible to getting lost in the beauty of nature and being less focused on what is going on with the client. He advises clinicians to be aware of how the counselor-client interaction might differ in an outdoor setting versus an indoor setting.

“It’s not that you don’t allow yourself to engage in the experience too. It’s just making sure that the client is ultimately who you’re there for and not yourself,” Reese says. “Sometimes, I just get the vibe [from people who want to] do this outdoor work … that it’s more about the clinician than it is about the client.” Thus, counselors need to be mindful of their own reasons and motivations for incorporating nature into their practice.

More than a ‘beautiful backdrop’

“Ecotherapy is one of those techniques that therapists and counselors can have in their toolbox, but they also need to know how to use it effectively,” Hasbach asserts. Ecotherapy goes beyond simply walking in nature or playing with a dog, she points out. Instead, she explains that it involves a triadic relationship between the client, the counselor and nature.

Thus, nature operates as a therapeutic partner. “[Nature] is an active agent in the work that we’re doing with our clients. It’s not just a beautiful backdrop,” Hasbach says.

Hasbach, a pioneer in the practice of ecotherapy, has co-edited two books on the subject — Ecopsychology: Science, Totems and the Technological Species and The Rediscovery of the Wild. She stresses the importance of incorporating a “nature language,” which is a way of speaking about patterns that represent how humans interact with nature in meaningful ways, such as sleeping under the night sky. “These interactive patterns can be really powerful if [clinicians] use them skillfully and intentionally in asking clients to incorporate them into some of their homework,” she says.

Hasbach had one client who was struggling with the end of an important relationship. Hasbach knew the client was a good photographer, so she asked her to take photographs of the sunset while contemplating the end of this relationship. The client’s journal of the experience reflected the similarity between the ending of the light and her relationship. Without being asked, the client also brought in a portfolio of sunrise pictures to discuss how this was also a new beginning for her — which was going to be Hasbach’s next assignment.

Nature can also operate as a metaphor in therapy. “There [are] metaphors in nature every day about things that we’re going through in our lives that can be powerful,” Delaney points out.

For example, Reese asked a client who had severe anxiety to identify with a section of the path they would walk. The client picked a picnic table with a view of a river. “We would go there each time, and we would talk about his view of that experience and his view of himself in that experience and how it continued to change. … Over time, he would go there on his own, and to me, that was the real special part,” Reese says.

Hasbach keeps a basket of 20-25 nature objects such as stones, feathers, shells and pieces of bark in her office. When clients are struggling for words, she asks them to see if any of the objects depict what they are feeling. Hasbach once had a client who was depressed about a breakup, but the client initially had a hard time talking about it. Hasbach asked the client if anything in the basket resonated with her in that moment, and the client picked out a naturally woven ball of vines. She said she felt like her life was a tangle and empty inside, just like the ball of vines. “It was just a prop that allowed her to be able to begin to talk about what she was feeling,” Hasbach says.

Nature can also be a metaphor for resiliency, Delaney points out. “After a … forest fire, the forest regrows. It starts over. It regenerates. It heals. Those are things we can talk about with our clients — being able to see how nature is reborn from even that horrific experience. … [The client’s] natural tendency as a natural being or animal being is to be resilient and to finds ways of growing and rebuilding.”

Connecting through nature

Reese also finds that engaging nature as a co-facilitator helps with building trust between the counselor and client. “Whether we are out in [nature] or we’re talking about it inside, that’s what we’re connecting through. We’re talking about [the clients’] nature connection,” meaning what they like doing outdoors. “We go for a walk. We just talk about other kinds of things, not their issues, and then, inevitably, what comes up are their issues,” he explains.

“[Nature] doesn’t explicitly judge you,” Reese continues, “[so] that offers … a pathway for people presenting with trust challenges, which [are] oftentimes based in relational trauma.” The fact that clients can talk and process in a space where no one is critiquing or yelling at them can be restorative and healing, he adds.

Reese has been piloting the Fishing for Wellness project with an alternative treatment community for people presenting with adverse life experiences. He explains that for clients dealing with complex trauma, building trust and engaging in conversation directly can be difficult. So, Reese integrates fishing as a means of creating a nonjudgmental space that bolsters wellness and mindfulness.

While teaching clients the mechanics of fly-casting and the general principles of fishing, Reese talks about being open to experiences and accepting of one’s self in the casting process. If clients get frustrated, Reese checks in with them and often slows the process down. Once, when a client was upset that he wasn’t catching any fish, Reese asked him to put down the fishing rod and pay attention to what was happening for him in that moment. Next, he invited the client to notice one thing he found beautiful or appreciated around him. Later, he processed what this experience was like for the client and what it brought up. Together, they identified patterns around the client’s frustration tolerance and behaviors in his life.

“The nature piece is a window into people’s challenges [and] presenting problems, and it’s also this amazing coping resource, especially when people can develop an effective connection with it,” Reese says. “The goal is that [clients] begin accessing some of these outdoor resources on their own without [the counselor].”

Some nature-based techniques work well with certain mental health issues. For example, Hasbach has found that walk-and-talk therapy is often effective with teenagers and people who are dealing with anxiety and social skills deficits. These clients typically find it more comfortable to walk side by side with the counselor rather than sitting and looking at each other face-to-face, she says.

Hasbach also believes that nature-based interventions are effective for clients with posttraumatic stress disorder. “It’s a way of helping [clients] recognize this calming effect that nature can have and this sense of belonging because many times, they feel very disassociated. So, this sense of belonging to something bigger than [themselves] can be very helpful,” she explains.

Integrating nature into holistic wellness

Even after dispelling the myth that ecotherapy must involve complete immersion into a natural setting, counselors still might find it difficult to think of nature-based techniques that work well in office settings. After realizing there wasn’t a clear guide on how to intentionally incorporate nature into a traditional counseling setting, Reese, along with the late Jane Myers, who was a leading proponent of wellness in the counseling profession, developed the EcoWellness model. It explores the extent to which one’s connection to nature affects wellness. The model includes seven domains — physical access, sensory access, connection, protection, preservation, spirituality and community connectedness — that are correlates of wellness.

The EcoWellness model “is not necessarily a specific intervention. … It’s more of a way of thinking or conceptualizing how to be effective in integrating this human-nature connection into counseling,” Reese says. Other wellness models do not explicitly mention the nature connection, but nature is another part of wellness and a way to aid in the healing process, he adds.

Because research clearly shows the wellness effects of nature contact, Reese encourages all counselors to include nature-based questions (for example, how much time clients spend outdoors, what clients enjoy outdoors) in their intake process, even if they simply ask clients about their experience outdoors in the context of exercise or physical wellness. He argues that if a client’s relationship with nature isn’t included in the intake process, then counselors are missing out on a vitally important part of holistic wellness.

Reese addresses the seven domains of EcoWellness with all of his clients by having a conversation with them about their experiences with nature. “My goal is to develop a pretty contextualized understanding of what that person’s connection with nature is like, how they benefit from it [and] how they don’t benefit from it,” he says.

Hasbach also weaves in a few questions in the intake session to gain a better understanding of clients’ histories and current interactions with nature. Sometimes the answers to these questions also reveal details about clients’ family life, she adds, such as hunting with their grandfather or hiding in the woods to escape violence in the home. Her questions include asking what recollections clients have about being outside in nature as a child, what their family members’ views were of the natural world, what clients like to do outdoors now and how often they engage in that.

Too often, clients’ connections to nature are left out of the conversation. These initial nature-based questions demonstrate that it is an appropriate topic and invite clients to discuss it in a therapeutic setting, Hasbach explains. In addition, the questions help counselors determine the best approach for integrating nature into therapy based on the client’s personal experiences.

Hasbach also finds eco-genograms to be a helpful technique for discovering clients’ connections to nature. Counselors often use genograms to encourage clients to think and talk about their family histories in more depth, but, traditionally, only people are included in genograms, Hasbach says. With eco-genograms, clients can include pets or even natural elements such as mountains or rivers that were important to them. They can also include facts such as living near a farm, having a garden or hunting their own food, Hasbach explains.

Counselors shouldn’t assume that everyone’s early experiences with nature were positive, Hasbach warns. That is why asking about a client’s experience with nature as a child during the intake session is important. If a client discloses that he or she had a frightening experience in the woods, then the counselor shouldn’t take the client on a walk in the woods. “[Clinicians] have to understand the client’s experience of the natural world, just like [they] have to understand the client’s experience of society, family [and] interpersonal relationships,” Hasbach explains.

In fact, taking clients outdoors may not always be beneficial for them, Reese notes. One of his clients who had been assaulted by a man told Reese that she didn’t feel comfortable working with him in an outdoor space. When they went back into the office, the dynamic shifted, and she felt safer.

Bringing nature inside

There’s good news for counselors who are hesitant about taking clients outside: They can stay inside and still use ecotherapy.

“The logistics of … meeting in a park or going to a specific place for individual sessions can present a challenge for many clinicians,” Hasbach notes. Instead, counselors can assign nature-based homework for clients to extend the therapeutic hour, she advises.

Hasbach and Delaney both find that nature-based assignments encourage clients to go outdoors, unplug from technology and incorporate the healing and restorative aspects of nature outside of the session.

For example, Hasbach sometimes asks clients to sit in their backyards or to take a walk on the beach and think about a question with which they’ve been struggling. She also uses a “special place” assignment in which clients select a special place that they agree to visit several times each week — during varied weather conditions and at different times of the day — for a specific number of weeks. This exercise fosters heightened sensory perception, a reconnection with and expanded knowledge of a natural place, and a sense of belonging, Hasbach explains.

Counselors can also make their office spaces greener. Hasbach first realized the powerful influence of nature during an office session before she was intentionally incorporating ecotherapy into her practice. On this particular day, she forgot to turn on a water feature that she regularly used. During her first session, the client noticed and asked about the absence of the water sound.

This experience taught Hasbach to be mindful of the elements in her office setting. She still has a rock fountain that provides the soothing sound of trickling water, and she often brings in freshly cut flowers. She has also purposefully arranged her office so that her clients face a window overlooking a tree canopy.

Research supports this idea of greening the office space. As Delaney points out, high-quality natural light from windows has been shown to decrease employee discomfort and improve productivity. As a result, she advises counselors to let in more natural light to their offices when possible, add plants, put up pictures of natural places and play nature sounds such as gurgling streams and distant thunder. Delaney even uses her computer screen as a way of displaying various nature scenes.

Technological nature

With an increase in urbanization and technology use, people often can find themselves even more removed from the natural world and spending more time in front of screens than outside, Hasbach points out. According to a 2010 Kaiser Family Foundation report, children ages 8-18 spend more than 7.5 hours a day on average with media. Common Sense Media reported that the amount of time young children (up to age 8) spent on mobile devices tripled from 15 minutes a day in 2013 to 48 minutes a day in 2017.

“Technology is with us,” Hasbach acknowledges. “We are technological beings as well as natural beings. We have always been toolmakers, so it’s not going away.” Rather than fight that fact, counselors need to help clients achieve a better balance between their technological and natural selves. “Richard Louv [author of Last Child in the Woods: Saving Our Children From Nature-Deficit Disorder and The Nature Principle: Reconnecting With Life in a Virtual Age] … says, ‘The more high-tech we become, the more nature we need,’ and I think that speaks beautifully to the balance that we have to find,” Hasbach reflects.

It is perhaps fortunate then that technological nature — digital representations of nature, including nature music and videos — can have benefits for one’s well-being. Research suggests that technological nature has similar properties to the real thing, Reese says. Although being out in nature is most effective, technological nature is better than no nature at all, he adds.

In 2016, Reese co-authored a study published in The Journal of Humanistic Counseling that examined the use and preferences of nature media accessed through YouTube and found that people often use nature media to help them sleep, study or destress. “People are still accessing a form of nature even in digital form and saying that they are benefiting from it,” Reese says. This finding might help counselors and clients expand their concept of what nature can be, he adds, especially for people who may not have easy access to outdoor spaces or those presenting with a severe pathology such as paranoid schizophrenia or severe obsessive-compulsive disorder. Thus, for people with no access or limited access to nature, such as those in prisons, nursing homes or health care environments, technological nature can play an important role.

Hasbach was part of a study that incorporated nature imagery into a prison that used solitary confinement to determine if it would affect the inmates’ behavior and well-being. The inmates spent either 23 or 24 hours per day confined to individual cells. Four or five times each week, they were allowed to spend an hour alone in the exercise area (another cellblock) or the recreation yard (a concrete enclosure with the top open to the sky).

The prison installed a projector in the exercise cell. Half of the inmates were given the option of watching a nature video during their hour of exercise time; the other half were not. The findings revealed a 26 percent decrease in violent offenses among the inmates who watched the nature videos. When Hasbach interviewed some of the inmates, she learned that the natural scenes had a restorative value for them. Some inmates said that when they were agitated, recalling the nature scenes helped them calm down. Hasbach explains that they were using the images to self-regulate.

However, Hasbach is concerned that technological nature may become a convenient substitute, even when real nature is available, especially in schools. Instead, she stresses that counselors should incorporate technological nature only as an augmentation to authentic nature.

Ethical considerations

Hasbach identifies confidentiality, avoiding harm and competency as three ethical considerations central to ecotherapy. Reese says he has encountered negative reactions about including EcoWellness in counseling in part because some counseling professionals have concerns about how to implement it ethically. Thus, both Hasbach and Reese recommend that counselors who want to pursue nature-based work have a solid plan for what they are doing, why they are doing it, what their hopes or outcomes are and how they can incorporate nature to be most beneficial to the client.

In terms of confidentiality, counselors and clients need to discuss the differences between going outside for a session and staying inside the office, Hasbach says. Among questions to consider: What happens if you and the client are discussing a sensitive issue on a trail and someone walks up behind you? What if you encounter someone whom either you or the client know? What happens if the client gets emotional on a trail?

After having a discussion, Hasbach documents how clients say they want to handle these situations. Some clinicians might take it a step further and have clients sign a waiver, she notes. Counselors also need to ask clients about allergies or physical limitations and document those as well. Reese spends at least two sessions indoors with clients discussing these possible scenarios and clients’ concerns before he even thinks about taking them outside.

Physical safety is another big consideration when working with groups, Reese says. “[Group work] adds an element of risk. You’ve got more people that you need to manage … so having a co-facilitator, having at least another person there who can help, in my mind is really important for the physical safety [of clients].”

Counselors must be competent and prepared for the environment they are taking clients into, Hasbach emphasizes. Walking on a bike path or working in a garden outside a home office doesn’t require as much physical competency as taking clients out by a river where they could be walking on rocks and have a heightened level of wilderness, she explains. Whenever she goes outside with a client, she takes a small emergency bag with a cell phone, water and allergy medicine. She says the only time she has had to use this bag was when offering water to a client who had gotten emotional.

Finding a balance

Melbourne’s email-a-tree initiative aimed to help with city maintenance, but it also revealed people’s need to reconnect with nature and find a balance between their technological and natural selves. It also reaffirms Louv’s claim that the more high-tech we become, the more we need nature.

“We are nature. We are a part of it, not apart from it,” Hasbach says. Ecotherapy provides a healthy environment for counselors and clients, and it gives clients permission to admit that they are out of balance and need to change, she continues. Ecotherapy also provides counselors and clients with tools to help clients balance the pace and stress of life, she adds.

For Hasbach, helping humans reconnect with nature and find (or rediscover) their balance is an exciting area for the counseling profession to explore. “When we really look at what is at the heart of people’s well-being, the environment that we’re in is part of that, so I think ecopsychology and ecotherapy [have] a [role] to play.”




Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. She has written on topics including health, social justice and technology. Contact her at or through her website at


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Finding balance with bipolar disorder

By Laurie Meyers April 24, 2018

Licensed professional counselor (LPC) John Duggan didn’t plan on bipolar disorder becoming one of his specialties, but providing emergency room support gave him a close-up view of the consequences when the disease was left uncontrolled. Duggan, who is also a licensed clinical professional counselor (LCPC), noticed the escalation in manic and hypomanic crises that accompanied the increased light and time change in spring. He also saw people who had been diagnosed with depression but whose manic or hypomanic symptoms had gone undetected until they ended up in the emergency room with full-blown mania, psychosis or dysphoria.

Some of these individuals had no one to help them remain stabilized after leaving the hospital. Seeing the need for, as Duggan puts it, “boots on the ground,” he began seeing more and more clients with bipolar disorder in his private practice in Silver Spring, Maryland. Duggan, who is now the manager of professional development at the American Counseling Association, says some of those clients came as referrals from counselors who didn’t feel qualified to work with individuals struggling with bipolar disorder.

It is not uncommon for counselors to be hesitant to take on clients with a bipolar diagnosis, according to practitioners who specialize in the disorder. At the same time, there are many individuals with bipolar disorder who truly need the support of counselors and other mental health professionals to help them manage their condition. Although the public — and perhaps even some mental health professionals — may think that the disease is rare, the National Institute of Mental Health (NIMH) estimates that approximately 2.8 percent of U.S. adults currently have bipolar disorder and that 4.4 percent will experience it in their lifetime. NIMH also estimates that approximately 2.9 percent of adolescents currently have bipolar disorder.

Some mental health practitioners may buy in to the stereotype that clients with bipolar disorder are volatile and resistant to treatment, whereas others may be daunted by the disorder’s elevated risk of suicide. The Substance Abuse and Mental Health Services Administration estimates that for those with bipolar disorder, the lifetime risk of suicide is at least 15 times higher than it is for the average person. However, Duggan and others who treat bipolar disorder say that counselors have a crucial role to play in helping clients manage the disease.

Bipolar basics

Counselors are already trained to obtain a detailed client history that includes, among other things, emotional symptoms, family history and sleep and lifestyle habits, all of which can be crucial to spotting bipolar disorder.

“Bipolar clients often seek help only when depressed. Because of this, their manic or hypomanic symptoms are often not reported or observed,” explains Valerie Acosta, an LPC who counsels a number of clients with bipolar disorder in her Richmond, Virginia, practice.

A first step is for counselors to educate clients. Although they may be familiar with the symptoms of depression, they are much less likely to know how mania or hypomania present, adds Acosta, a member of ACA. Many clients think mania involves feeling very “up” and happy, but symptoms actually include intense irritability, anxiety and distraction, she explains.

Sleep patterns are also instructive when looking for evidence of mania or hypomania, says Regina Bordieri, a licensed marriage and family therapist in New York who specializes in bipolar disorder. “If they’re not sleeping, are they feeling energetic or tired?” she asks. Most people feel tired after a short night’s rest, but in hypomanic or manic phases, those with bipolar disorder feel energized despite very little sleep, Bordieri explains.Bordieri also asks clients about times when they weren’t depressed. Did they have high levels of energy and feel like they could get a lot done? Depressed moods that alternate with periods of intense activity and feelings of almost limitless energy may be signs of bipolar disorder.

Because it can be difficult for individuals to recognize their mood and behavioral shifts, family members and partners can also play a significant role when it comes to identifying and gauging symptoms, Bordieri says. Then, of course, there is the other role that family plays in diagnosis — namely, family history. Bipolar disorder is strongly tied to genetics, so clients with a family history of bipolar disorder are more likely to develop the disease.

Duggan urges counselors who are treating clients with bipolar disorder to work closely with medical professionals. Consulting a client’s primary care physician (with the client’s permission) is particularly crucial during diagnosis so that physical causes such as sleep disorders, thyroid disorders or a reaction to medication won’t be mistaken as symptoms for bipolar disorder.

Counselors — and clients — should also be aware of their ideas concerning which symptoms and forms of bipolar disorder are most debilitating, say Acosta and Bordieri.

“Bipolar II is not a milder form of bipolar I, but a separate and different diagnosis,” Acosta explains. “Bipolar I is also not necessarily more difficult to treat. … While the manic episodes in bipolar I can be severe and dangerous, the depressive episodes associated with bipolar II can be longer lasting, causing severe impairment to the individual. While clients with bipolar II have hypomania and not full manic episodes, their depressive episodes can be more debilitating than the depressive episodes of bipolar I.”

Although the depression of bipolar II may take a greater overall toll and be harder to treat, the mania inherent in bipolar I comes with its own set of “baggage.” In the popular imagination, mania — especially more extreme episodes — is the phase most associated with bipolar disorder and contributes to the perception that those who have the disorder are “crazy.” Mania is also extremely disturbing for clients and is highly stigmatized, especially when it leads to hospital stays, Bordieri says.

Ultimately, however, each client’s experience of bipolar disorder is different, Acosta says. “A therapist might be working with two people with bipolar II, and these individuals may present with very different symptoms,” she says. “Helping clients and their families to understand the individual’s unique symptoms, and have a variety of tools and strategies for managing their moods and specific symptoms, is essential for recovery.”

Managing medication

The counselors interviewed for this article stress that because of the neurobiological nature of bipolar disorder, medication is an integral part of treatment. Cheryl Fisher, an LCPC practicing in Annapolis, Maryland, whose specialties include bipolar disorder, says that counselors should work closely with a psychiatrist when treating these clients. In fact, when Fisher sees new clients with bipolar disorder who are working with a primary care physician, she strongly urges them to begin seeing a psychiatrist. Fisher, a member of ACA, believes that psychiatrists possess the specialized psychopharmaceutical knowledge necessary for prescribing the medication “cocktail” that works best for each individual with bipolar disorder. And because counselors see clients more often (and for longer chunks of time) than their physicians do, Fisher thinks that counselors are in a better position to track the effectiveness and side effects of clients’ prescriptions.

Counselors can also help clients become better self-advocates, says ACA member Dixie Meyer. Sometimes clients aren’t comfortable speaking up at the doctor’s office or are unaware that they are even experiencing side effects, she says. Counselors are in a position to spot such problems.

Meyer gives the example of a client who was showing signs of lithium toxicity. “I asked him when was the last time he had his blood levels checked [lithium requires regular blood testing to guard against toxicity]. He asked me what I was talking about. Somehow, he never knew he needed to have levels checked regularly.”

Meyer, an associate professor in the medical family therapy program at the St. Louis University School of Medicine’s Relationships and Brain Science Research Laboratory, says counselors should also be aware that clients with bipolar disorder might be given antidepressants for depression that can cause the onset of mania or hypomania.

“Clients might feel like, ‘Wow, I’m really starting to have a good mood,’” she notes. “They don’t really think to bring that up to the doctor, but the counselor can easily recognize the difference between remission of depression symptoms versus the development of manic symptoms. [Clients] might become more impulsive, snippier, their motor behavior more agitated … Counselors and family members are often the best [resources] to spot mood shifts.”

Sometimes clients don’t want to take medication for bipolar disorder because they have experienced unpleasant side effects, says Meyer, who frequently gives presentations to counselors on the importance of understanding their clients’ medications. She urges counselors to talk through this decision with clients. Meyer informs her clients with bipolar disorder that all medications have side effects, some of which may be temporary. She then asks these clients to give the medications some time and encourages them to talk to their physicians about which side effects might be permanent.

If the side effects of the medication aren’t going to go away, Meyer talks with clients about whether the side effects are something they can live with. In some cases — especially with medications that cause significant weight gain — the client’s answer is no. In those situations, Meyer says that she, the client and the physician go back to the drawing board and look for other medications or explore whether lifestyle changes might help reduce the side effects.

Meyer says all counselors should have a copy of the Physicians’ Desk Reference on hand so that they can quickly look up any medication. She also recommends as an excellent online resource.

Sometimes clients with bipolar disorder get stabilized and decide that they don’t need to take their medications anymore. When that happens, Acosta says that she “reflects back” what happened the last time the client stopped taking his or her medication. (Spoiler alert: It wasn’t good.)

Fisher tries to educate clients about bipolar disorder, emphasizing that a biochemical reaction underlies their mood shifts and that the medication helps buffer that process.

Medication, however, is not the only tool in the box to help individuals with bipolar disorder. Counselors can provide the emotional and lifestyle keys that help clients manage and, hopefully, decrease their mood and behavior shifts.

Prevention and stabilization

Multiple research studies continue to demonstrate the link between the circadian rhythm and bipolar disorder. Researchers are still teasing out the specifics, but what is clear is that maintaining a schedule — particularly a sleep schedule — that hews to the circadian rhythm plays a key role in controlling the disease.

Research has shown that insomnia is not just a symptom of depression but can also cause it. Likewise, Bordieri says, disturbed sleep can be either a symptom of hypomania/mania or the trigger for an episode.

Sleep is one of the first things that Fisher investigates with all clients, but it is particularly important in those with bipolar disorder. “I ask them what their sleep routine is,” she says. “How do you end your day? How do you prepare your body to rest? What is your sleeping environment like?” Fisher talks about how the blue light from devices such as smartphones and tablets disrupts sleep and advises clients to establish total darkness in their bedrooms.

Some clients reveal that a racing brain regularly prevents them from going to sleep. For these clients, Fisher recommends tools such as guided meditation or performing what she calls a “brain dump” — emptying the mind by writing down all of the thoughts that are keeping clients awake.

Acosta encourages clients with bipolar disorder to go to bed at the same time every night, wake up at the same time every day and take their medications at the same time daily. She has found this routine has a stabilizing effect.

Fisher and Duggan both believe sleep is so essential to mental and physical health that if good sleep hygiene isn’t working, they advise clients to get a sleep aid from their physician.

Duggan has found that the changing of the seasons can also have a profound effect on bipolar disorder. It’s a component of the bipolar resiliency program he came up with called SMART.

S — (Control) stress, sleep, maintain a schedule, seasons: Duggan asks clients with bipolar disorder to track their moods and sleep. He also teaches sleep hygiene and makes note of clients’ responses to the different seasons. Summer, when there is a lot of activity going on and plenty of sun, is usually a good time for many clients with bipolar disorder. But as the season draws to a close, Duggan reminds them that once fall arrives and there is less light, they are likely to start feeling less upbeat and may feel overwhelmed. He urges these clients not to overschedule themselves in summer and to step up their self-care efforts when the calendar turns to September.

M — Medication as prescribed

A — Adjunctive treatment such as yoga, acupuncture, massage or other complementary or alternative practices: Duggan says these are all areas that are outside of his expertise but that clients have found helpful. He also works with clients on self-soothing techniques and meditation. If a client is going through a severe manic or depressive phase, however, he strongly recommends against mindfulness. “I don’t want them to ‘be’ with the bad depression or the bad mania,” he explains.

R — Recreation and relationships: Duggan urges clients with bipolar disorder to stay engaged socially and to “do things that bring you joy, that you love, that give you a sense of flow.”

T — Therapy and counseling as needed

Fisher is a proponent of what she calls “nature therapy.” Research has shown that nature has a beneficial effect on mental health, so she urges clients to find a way to get outside — even if only for a short time — every day.

“Encouraging clients to track their moods can be a very valuable tool,” Acosta adds. “There are a wide variety of apps that clients can download to help with tracking their moods. Daylio is one that a lot of my clients like to use. By recording this information over time, clients learn about how their moods cycle, and this helps them to better understand the nuances of their moods, their triggers, and what helps and does not help with stabilizing their moods. I routinely review data from these apps — or paper mood charts — with my clients. I also routinely review symptom charts with my clients to help them monitor their symptoms.”

Some of Acosta’s clients have also had their own highly personal methods of tracking problematic mood changes. One client monitored her mood elevations by the number of packages that appeared for her in her apartment lobby (overspending). Another client could connect his manic symptoms to times when he would spend several days engrossed in building things (an increased focus on goal-directed activities).

Developing this degree of self-awareness can be beneficial for clients with bipolar disorder. “Linking symptoms to behaviors, thoughts and triggers can help to foster recovery,” Acosta says.

Meyer also teaches clients to spot patterns. She has premenopausal women chart their menstrual cycles so they will be aware, for example, that three days before their periods begin, they will feel more depressed. Meyer instructs clients to note their moods throughout the day and record what was going on. She believes that when clients can identify these patterns and recognize that there was a specific reason they were particularly manic or depressed, it provides them a greater sense of control.

Meyer teaches clients to self-soothe on hard days by going for a walk, going to the park and sitting on a bench or doing whatever else makes them feel good in a healthy way. 

“It’s really important … that our clients be empowered with a strategy for their symptoms,” Fisher says. For instance, if clients with bipolar disorder are having a down day and feel as though they are shifting toward a depressive episode, they could start to manage the switch by making a plan to get together with a friend or even just calling someone close to them.

Acosta tries to equip clients with bipolar disorder against life stressors. “They need to find healthy ways to cope with stress,” she says.

Acosta teaches clients mindfulness meditation and gives assignments outside of session, such as trying yoga or a new form of exercise. She believes that physical activity helps rein in racing thoughts. Acosta also recommends music for relaxation.

Seeking support

In addition to individual therapy, Acosta has found that group therapy is very effective for clients with bipolar disorder. She runs a monthly support group for adults over 18. “Some participants have been living with bipolar disorder for decades, and some have just been diagnosed,” Acosta says. “This is an open group, so members are constantly joining and leaving the group. On average, we have three to 10 participants per group. Because this is a therapy group, participants bring in and discuss any issue that they’re currently dealing with in their lives. Some of the topics of discussion include challenges such as the struggle to be on time for work or losing a job because of their bipolar symptoms, relationship conflicts, the side effects of medication, healthy strategies for managing symptoms, grieving the losses in their lives caused by their illness and building healthy living strategies.”

Acosta also provides education as needed in the group on topics such as understanding symptoms, exploring apps to track mood and locating resources for further education and support. She believes the peer support is what is most helpful to group participants.

“Many people have never met someone else with bipolar disorder, and learning that they are not alone or the only person dealing with the challenges of bipolar disorder can be extremely comforting and helpful,” she says. “Seeing peers recover, build healthy relationships and obtain their goals and dreams is most powerful.”

Support for these clients is essential, agrees Meyer, who recommends that counselors help recruit family members and romantic partners as a kind of support team whenever possible. Loved ones can be there when counselors can’t and are often the first to spot mood changes, she explains. “We also know when clients are in good, healthy relationships, it helps stress levels, and that helps keep them in good health,” Meyer adds.

Sometimes support can come from the strangest of sources, notes Fisher, relating the story of a woman who was in particular need of connection. “I had a client who had a trauma history in addition to bipolar disorder, and she was engaging in really unhealthy behaviors and self-loathing. She was just not in good shape,” Fisher says. “She came in one day, I did a checkup, and she showed really high levels of depression.”

Fisher didn’t think the client was in immediate danger, but she felt bad leaving her without another source of support, particularly because it was a Friday and Fisher was going away for the weekend.

“I asked, ‘Who can you be with? Who can you talk to?’’ Fisher says. “The client said, ‘No one. There is no one.’”

The woman was estranged from her family, and her only “network” involved her sexual hookups.

Suddenly, Fisher had an idea. She had just bought a betta fish for her office, so she asked the client to watch it for her over the weekend.   

Fisher saw the client the following Monday — sans fish — and asked how she was doing. The client replied that she was feeling better and more upbeat.

“Then she started talking about her weekend and spending time with ‘Olive’ and watching TV with ‘Olive,’” Fisher continues.

She asked the client who Olive was. Olive was the name the client had bestowed on the betta fish. The client had neglected to bring Olive back because she didn’t want to leave the fish in the car but promised to return her later in the week.

Fisher told the woman to keep the fish but was curious as to why she had named her Olive. The client said that Olive made her think of hope — like the olive leaf the dove brought back to Noah’s Ark to show the waters were finally receding after the Great Flood described in the Bible.

What lesson did Fisher take away from this experience? “We have to get our clients to connect — even if it’s just with a betta fish,” she says.

Fisher urges counselors to overcome any reservations they might harbor about treating clients with bipolar disorder. “Get more training if you’re uncomfortable,” says Fisher, who encourages counselors to ask themselves why they might be uncomfortable and then to address those reasons.

Counselors already possess the skills needed to empower these clients, Fisher adds. “We have clients who are walking in the door with this diagnosis and identifying it with who they are,” she says. “Bipolar disorder is not who they are — their diagnosis is not their identity. People think, ‘My body is betraying me. I feel like crap. I’ve alienated all my friends — I am the monster.’ Counselors can exorcise the demon of the [bipolar] diagnosis.”




Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (

Books (

Podcasts and webinars

  • “Bipolar Resiliency Program” with John Duggan (HT056)
  • “Depression/Bipolar” with Carman S. Gill

Practice briefs (

  • “Counseling Adults Who Have Bipolar Disorders” by Victoria Kress, Stephanie Sedall and Matthew Paylo




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

Letters to the




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.


Behind the Book: Counselor Self-Care

By Bethany Bray April 23, 2018

There is no perfect plan when it comes to self-care. The important thing is to have a plan and make self-care a career-long focus. Not only will the methods that counselors find effective vary from practitioner to practitioner, but a self-care routine will also need to evolve to meet changing needs throughout a counselor’s career.

“No one person has the ideal formula for optimal self-care; We are unique individuals with varied life experiences,” write the co-authors of Counselor Self-Care. The book, recently published by the American Counseling Association, compiles the insights and personal self-care journeys of more than 50 counselors from across the profession in various stages of their careers.

Counseling Today sent the co-authors some questions, via email, to learn more. Gerald Corey is an ACA fellow and professor emeritus of human services and counseling at California State University, Fullerton; Michelle Muratori is a senior counselor at the Center for Talented Youth at Johns Hopkins University in Baltimore; Jude T. Austin II is an assistant professor in the Counseling and Human Services Department at Old Dominion University; and Julius A. Austin is an assistant professor in the Marriage and Family Therapy and Counseling Studies program at the University of Louisiana at Monroe.



Q+A: Counselor Self-Care

Responses co-written by Gerald Corey, Michelle Muratori, Jude T. Austin II and Julius A. Austin


Why, in your opinions, is self-care considered an ethical mandate?

Simply put, we can place our clients in danger when we do not take care of ourselves as counselors. It is hard for us to believe that counselors can make sound decisions regarding their clients’ welfare when they are struggling to make sound decisions about their own welfare.

Self-care as an ethical mandate involves taking active steps to acquire and maintain wellness in all aspects of living. The concept of wellness is a lifelong journey that has implications for us both personally and professionally. We sometimes hear that self-love and self-care are signs of selfishness. As co-authors of this book, we believe that it is not a matter of self-care versus caring for others. It is surely possible to be invested in both. We may feel invested in promoting a good life for others and be instrumental in improving conditions in our communities. But to be genuinely involved in social action and bettering society, we need to begin with ourselves. Taking time to reflect on the quality of our lives is a good beginning for making changes in our behavior that will lead to increased wellness.

If we neglect caring for ourselves on a regular basis, our professional work suffers, so self-care is a basic tenet of ethical practice. If we are drained and depleted, we will not have much to give to those who need our time and presence. The prevention of burnout and the commitment to monitoring ourselves is a cardinal ethical principle. The 2014 ACA Code of Ethics includes the statement that “counselors engage in self-care activities to maintain and promote their own emotional, physical, mental, and spiritual wellbeing to best meet their professional responsibilities” (Introduction to Section C, Professional Responsibilities). Meeting this ethical standard is not a final event, but instead it is a call for counselors to reflect daily on what they are doing and the degree to which their behavior is working. Self-care can be thought of as a set of practices that prevent emotional depletion and burnout.

Books and chapters, as well as articles in the professional journals are being written on counselors focusing on prevention of burnout, as well as learning to manage personal and professional stress. One example of this is Counseling Today’s recent article “The Battle Against Burnout” (the cover story of the April issue).


In general, do you feel that new counselors emerge from graduate and training programs with an adequate understanding and focus on self-care?

We have not conducted any surveys on self-care in graduate programs, so we cannot answer this question with supporting empirical evidence. It is our assumption that counselor preparation programs do their best to give this topic some degree of attention. In fact, some programs may do a fine job of educating their trainees about the hazards of burnout and the necessity for self-care. However, understanding the concepts intellectually and experiencing the demands of the profession firsthand are two different things.

Each of us has heard from trainees during their practicums and internships that they are surprised by the intensity of the work and the stress that it produces. Too often students graduate and enter the early phase of their career with idealism and optimism, only to encounter barriers to achieving their professional goals and maintaining wellness. The amount of paperwork, responsibility, emotional energy, and strain on personal relationships are just a few things our students said they wish they would have known about before graduation. At times, their optimism wanes and their hopes to see changes are dashed, which leads to disillusionment, exhaustion, and early stages of burnout.

While we cannot speak with authority about programs in general, we can speak about what we do to encourage our students to develop self-care practices that will bode them well in graduate school and strategies that can enable them to prevent burnout. As co-authors of this book, the four of us take the ethical imperative of self-care very seriously and do our best to incorporate self-care activities and practices in the courses we teach and in our role as mentors with the many students with whom we work.

We think it is of paramount importance that faculty model attitudes and practices of self-care. Our students will be more impressed by who we are and how we interact with them than by our lectures on self-care. In our respective programs, many of our colleagues introduce a variety of self-care activities in their classes, including mindfulness exercises. Some of us encourage students to develop a self-care action plan, and to think of ways to make learning a personal journey rather than a strictly academic pursuit.


What resources would you suggest for a “veteran” counselor who has been working in the field for a while and is looking for ways to boost or update/refresh their self-care routine?

To update/refresh their self-care routine, experienced counselors need to endorse the value of lifelong learning, realizing that their education and development do not stop at graduation. One of the best ways to revitalize their self-care routine is to find new ways to connect to valued colleagues who share their passion for this work. Colleagues can serve as mentors long after we are into the professional field. Personally, we find attending professional conferences, workshops, learning institutes and other forms of continuing education to be valuable resources and networking opportunities. The four of us attend the ACA conference every year in addition to other professional meetings. We always come away feeling inspired, with new ways of thinking about topics that matter to us. We typically present education sessions and participate in learning institutes, and this affords us opportunities to work with students and counselors from various parts of the country. This is energizing for all of us! We also try to carve out time to enjoy lunch or dinner with colleagues, former students and friends in the area. We also intentionally make time to rest, sightsee and enjoy what the conference’s host city has to offer. These activities recharge our batteries and equip us with new tools to bring back to our students, clients and supervisees.

Besides keeping professionally updated, we are convinced that counselors who have worked in the field for a while can bring more vitality to their work if they are attending to their personal lives. Thus, engaging in various forms of recreation and hobbies are ways to refresh our self-care routine. Participating in travel can be taxing, but it can also broaden our perspectives and help to keep us interested and interesting. Another strategy is to try something new that has nothing to do with professional development. We might try a new sport, plant a garden, play a new video game, read a book purely for pleasure, learn a musical instrument or implement a new exercise routine. We must find ways to boost our routine when it starts to feel stale. What is critical is that each of us must find our own path for retaining our vitality, both personally and professionally.


Self-care that a counselor finds helpful will differ and evolve throughout their career. What would you want counselors to know about the need to change and adapt their self-care routine as they grow as a professional?

We would want counselors to know that self-care is a delicate process that is unique to each counselor. What works from some may not work for others. Moreover, a self-care plan that meets one’s needs at a certain point in one’s career may no longer serve us at a later time. There are likely to be many twists and turns in the evolution of our career; thus, we may need to be prepared to adapt our self-care practices accordingly. Being patient with this process and with ourselves as we navigate new personal and professional experiences is of the utmost importance.

As alluded to, even if we have been successful in establishing self-care practices as we begin our career, we are likely to find that we need to make changes as we take on new responsibilities. These stages include (1) graduate school; (2) early career; (3) mid-career; and (4) late career. Since each of the co-authors is presently in a different stage of professional development, we each describe challenges we face and how we do our best to thrive personally and professionally. In our book, Counselor-Self Care, we devote a chapter to self-care across the seasons of our career, in which we address this question in some depth.

Self-care involves unique challenges at each developmental stage in a career. For example, how we meet these tasks during graduate school has implications for how well we will be able to address them throughout our career. Transitions in life can be stressful, even when they bring about positive change. One such transition is leaving the safety net of a graduate program and launching a career as a new professional. Entering this next season of their life and career as early professionals can indeed be very exciting. However, it is a period when many changes occur and major life decisions are made.

As clinicians and counselor educators gain more experience in their professional roles and enter into the mid-career phase, it is likely that they will be expected to take on greater professional responsibilities, which are inherently stressful. For instance, clinicians may be promoted to positions that require them to supervise others and manage budgets while those pursuing positions in higher education may have to weather the challenges associated with going up for tenure. At the same time, they may be experiencing developmental stressors in their personal lives such as dealing with aging parents or children leaving the nest to go away to college or to enter the workforce. For mid-career mental health practitioners, the challenge involves becoming aware of developmental stressors, finding ways to maintain competence and assuming an active role in engaging in lifelong learning. This is a time for practitioners to continue to become aware of common risks for burnout and to monitor how well they are managing stress, especially with the increasing demands associated with a mid-career. It is important to adopt an active role in collaborating with colleagues and to avoid professional isolation and burnout.

The late-career professionals often are faced with adapting their lifestyle and self-care routines. Retirement is a part of this phase of one’s career. Retirement is an opportunity to redesign our life and to tap unused potentials; it is not an end to all work. There are many choices open to us as we embark on the path toward retirement. We can get involved with the projects we might have put aside due to the demands of our job. We can discover that retirement is not an end, but rather a new beginning. Retirement is a major transition in life that brings a variety of choices and transitions. A major developmental task we face as we retire is deciding which path we will take to continue to find meaning in life.


What prompted you to collaborate and create the book? Why do you feel it’s a relevant/needed topic to cover now?

A combination of factors prompted us to collaborate and create this book. Primarily, our relationships with one another as a collaborative team on various other projects sparked our excitement to work together again. While attending professional conferences, we had observed a large number of attendees at self-care presentations and had noted that self-care for mental health professionals was being given more attention in the literature. In addition, we noticed a number of our own students, supervisees and colleagues asking for more information about self-care and talking about how spread thin they were with all of their demands. When we initially brainstormed ideas, we realized that the book would have more depth if we brought our combined life experiences and perspectives to the project.

We aimed to write a book that presented diverse perspectives on self-care with the objective of encouraging counselors and counselor trainees to evaluate their present level of self-care and consider specific changes they want to make in attending to all aspects of wellness in their personal life. The book gives readers a chance to look into the lives of many different helping professionals as they wrestle with taking care of themselves.

The four of us are engaged in professional work in different settings and are at different stages in our careers. Two of us are early-career professionals, one of us is a mid-career person, and one of us is a person in his late career. Individually and collectively our aim was to offer a balance of challenge and support as our readers consider ways to enhance their personal and professional life through self-care.

Early on we decided to invite guest contributors to share their experiences in meeting the ethical mandate of self-care. We exchanged ideas on how we could reach our audience with the message “Counselor, take care of thyself!” Our many discussions led to our decision to include a wide range of students, counselor practitioners, and counselor educators to share their self-care stories. We were impressed with their levels of honesty and courage in disclosing their struggles and sharing the action plans they devised to treat themselves with increased kindness and compassion. Despite the obstacles our guest contributors encountered, their stories are filled with their hopes and visions for the future. Many themes were explored, including not demanding perfection in taking care of themselves, continuing to strive to do better despite occasional setbacks, asking for the help they needed, recognizing that consistency in self-care practice is essential to competently serving others and that self-care is a process.


What do you hope readers will take away from the book?

Our hope is that readers will be motivated to engage in honest self-reflection of where they are now and where they would like to be in their self-care program. After reading the narratives of 52 guest contributors about their experiences with self-care, along with our thoughts and experiences related to this topic in each chapter, readers can continue to implement a personal action plan that will lead to wellness in all aspects of their lives.

There is no perfect plan that will motivate us to achieve our self-care goals, yet if we have no plan it will be difficult for us to survive the demands of our professional work, let alone thrive in our lives and careers. It is our hope that students and counselors who complete this book will make a comprehensive assessment of their current behavior and determine what changes they want to make to better meet their needs — physically, emotionally, mentally, socially and spiritually.

As counselors, we have the responsibility to do whatever it takes to be as present and effective with our first client of the day through to our last. We need to remind ourselves that self-care is not a project that is completed once and for all, but rather it is a process of taking care of ourselves. We need to put ourselves in our schedule so that we will have the stamina to fulfill the many demands of our professional work. It is our expectation that readers will see that burnout and impairment are not inevitable. If we make self-care a priority, not only can we stave off burnout, but we can engage in daily practices leading to wellness.






Counselor Self-Care is available both in print and as an e-book from the American Counseling Association bookstore at or by calling 800-347-6647 x222


Attending the ACA 2018 Conference & Expo in Atlanta this month? Check out these events with the authors of Counselor Self-Care:

  • Wednesday, April 25, 9 a.m. to 4:30 p.m.: Learning Institute “Taking Care of Yourself: A Luxury or an Ethical Mandate?”
  • Friday, April 27, 11 a.m. to noon: Counselor Self-Care author content session
  • Thursday, April 26 from 4:30 to 5:30 p.m. and Friday, April 27 from noon to 1 p.m.: Counselor Self-Care author book signings

See for more details




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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.

@TechCounselor: Streamlining repeat emails

By Adria S. Dunbar April 16, 2018

No matter my professional role, there always seems to exist the need to send out the same email over and over again. Either I write the same email monthly or annually, or I write the same email and send it to multiple people.

When I was in private practice, it was a “New Client” email. As a school counselor, it was usually an introductory email to parents and students. Now, as a counselor educator, my repeat emails are related to admissions and advising. Regardless of the content, I can help you streamline this process to save yourself a lot of time.

The first step is to embrace Google Sheets. Even if you don’t enjoy Sheets (or similar software programs such as Excel or Numbers), I can promise you that Sheets is one of the best tools to help you manage your email. Create a sheet, or multiple sheets, with the following columns:

  • First Name
  • Last Name
  • Email Address

Those three columns are the basic necessities to make this work, but feel free to add others. Oh, and capitalization matters.

Once you have your columns set up on the first row of your spreadsheet and have input all of your data, click on “Add-ons” and then “Get Add-ons.” Search for “Yet Another Mail Merge (YAMM)” and download the software. Get ready to be amazed at how easy this is!

Compose an email to all of your recipients. You might want to include some personalization, such as “Good morning, {{First Name}},” or “Hello, Dr. {{Last Name}}.” Your spreadsheet might also include a column titled, “Appointment Date,” in which case you could include that in the body of your email. For example, “We are excited that you will be visiting us on {{Appointment Date}} and look forward to working with you.” Once your email is complete and saved (Google autosaves for you), you’re ready to use YAMM.

Go back to your Google Sheets. Click Add-ons > Yet Another Mail Merge > Start Mail Merge. Choose the Sender Name and the Email Template you’d like to use. YAMM gives you a list of your most recently composed emails. You can also choose to track emails to see if and when recipients receive or open your message. Finally, you can also delay your email to send at a specific date and time. This is great for those of us who tend to be working late at night or over the weekends. However, you can also send right away. In either case, you may want to use the “Send Test Email” feature just to be sure your email sends in the way you intended.

For even more advanced options, check out how to convert Google Docs to Emails using a Chrome Extension. This will help you create branded or creative email messages that will really impress your recipients.



Adria S. Dunbar is an assistant professor in the Department of Educational Leadership, Policy and Human Development at North Carolina State University in Raleigh. She has more than 15 years of experience with both efficient and inefficient technology in school settings, private practice and counselor education. Contact her at


@TechCounselor’s Instagram is @techncounselor.




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.

Counseling people who stutter

By Chad M. Yates, Karissa Colbrunn and Dan Hudock April 11, 2018

Kyle hears the drone of the elevator music playing behind the bland voice that states, “All calls are important to us. Thank you for your patience. A customer service representative will be with you in just a moment.” Kyle knows the message well because he has been on hold for nearly 15 minutes. While waiting, Kyle practices in his head the message he needs to state: “Hello, my name is Kyle, and I need to schedule a shuttle ride to and from the airport.”

Suddenly, a crackling voice replaces the music. “Hello, thank you for calling OK Shuttle. How can I assist you?”

Kyle feels his throat tighten and his chest begin to seize. “Hello, my name is Kyyyyyy, my name is Kyyyyyyy, Kyyyy.”

“Sir, are you there? Sir, are you there?” insists the customer service rep.

Kyle continues: “Hello, my name is Kyyyyle. I need to schedddddd … I need to schedddddd, scheddddd.”

“Sorry, sir,” the voice on the other line says. “We have a poor connection. Please call back again when your service is more reliable.”

The sound of the click thunders in Kyle’s ear as a tight-pitched squeal replaces the silence. Kyle looks down at his feet, too afraid to pick them up and move. He feels frozen in anger, disgust and helplessness. Fear precludes the idea of calling back again.

This experience is all too common for people who stutter (PWS). For these individuals, the experience of communication, which many of us take for granted, becomes a blockade that stands between connection, understanding and the navigation of one’s world.

Experts in the field of speech-language pathology define stuttering as a communication disorder involving disruptions, or disfluencies, in an individual’s speech. The cause of stuttering is typically thought to be a neurological condition that interferes with the production of speech. Although many children spontaneously recover from stuttering, for approximately 3 million U.S. adults (about 1 percent of the population), stuttering is chronic and has no cure. Despite this, there are ways to manage stuttering in both the behavioral sense (how much the person stutters) and the psychological sense (how much stuttering impacts the person’s life).

Situations such as the one that Kyle experienced can happen almost daily for PWS. The pain of these experiences often leads these individuals to isolate themselves from the things they love to do because the risk of communicating can feel as if it outweighs the benefits of living the life they want to live. Peer reactions to unusual speaking patterns can begin as early as age 4. These reactions persist and increase throughout adolescence, which can negatively affect many facets of life, including social relationships, emotional well-being and academic performance, for PWS. Adults who stutter have scored significantly lower in questionnaires regarding quality of life, specifically in regard to vitality, social functioning, emotional role functioning and mental health. Although various studies show that counseling is indicated with this population, many speech-language pathologists are not trained in counseling or do not feel comfortable with their counseling skills and abilities.

Interprofessional collaborations between speech-language pathologists and counselors can be considered best practice for helping PWS and other individuals with common communication disorders. Idaho State University’s counseling and speech-language pathology departments are involved in a unique relationship in which they are training both speech-pathology interns and counseling interns to work side by side to treat PWS. This treatment is provided through the university’s Northwest Center for Fluency Disorders Interprofessional Intensive Stuttering Clinic (NWCFD-IISC), which offers a two-week clinic for adolescents and adults who stutter.

The clinic is the first of its kind in which speech-language pathologists and counseling interns work together to treat the holistic needs of clients who stutter through acceptance and commitment therapy (ACT), a mindfulness-based mental health approach. We (the authors of this article) have conducted the clinic over four consecutive years. Through this experience, we feel that we can share recommendations for counselors working with PWS and with other clients who present with communication disorders. Additionally, we have observed key ingredients for interprofessional collaboration and can speak to strategies to build effective interprofessional teams.

Recommendations for counselors

To be effective working with PWS, counselors need to address the misconceptions they have about stuttering. Consulting resources, such as the National Stuttering Association and the Stuttering Foundation, that are supported by PWS can help counselors to debunk common myths associated with this population.

One common myth is that stress causes a person to stutter. Another myth is that taking deep breaths before one speaks can eliminate stuttering. We have heard countless “cures” for stuttering from the general public. These include placing spices under one’s tongue, receiving acupuncture and sitting or standing with the correct posture. These erroneous cures can be insulting and demeaning to PWS. At best, it is frustrating for PWS to hear these ideas repeated over and over again. Counselors should be knowledgeable about the lack of support for these types of cures while being able to point out to clients resources on effective treatments.

For PWS, reactions from listeners often can be painful. As PWS become more aware of their stuttering and encounter negative listener reactions to their disfluencies, they may develop negative emotions toward communication situations and begin to avoid speaking. The shame and guilt that PWS often feel for stuttering can lead to fear, anxiety and tension in relation to communication, as well as decreased self-confidence. PWS may develop secondary behaviors that they employ in hopes of alleviating their stuttering. These secondary behaviors might include avoiding eye contact, avoiding speaking to people in positions of authority and avoiding certain words that they anticipate stuttering. Being aware of this, it is important for counselors to understand the role that positive regard, expressed behaviorally through continuous eye contact or not averting their glance when PWS speak, can have on these individuals.

Working effectively with PWS also involves using positive and respectful communication practices. During conversations, time pressure can be present when PWS take longer to communicate. This can sometimes lead to one party attempting to finish the other’s sentences. To PWS, this behavior can suggest that their communication of ideas may not be as important as the other speaker’s time.

Finishing a person’s sentences is often done in reaction to uncomfortable feelings associated with the time pressure of communication. Counselors should be aware of when they are experiencing these feelings. They should continue to allow their clients who stutter to finish what they wish to say regardless of time pressure and regardless of whether these clients are having blocks (when sound or air is stopped in the lungs, throat or mouth/lips/tongue), breaking off speech or having repetitions (repeating a sound, syllable or word more than once or twice).

The final recommendation involves the use of person-first language. Often, PWS call themselves “stutterers.” Reframing the language to say a “person who stutters” can reduce the stigma that surrounds the word “stutterer.” This action also treats the person as an individual. During the NWCFD-IISC, we empower PWS and work to mitigate stigma by reinforcing the idea that what a person says is more valuable and important than the way he or she says it. We also affirm that all individuals deserve to communicate their thoughts and ideas.

Recommendations for interprofessional teams

Interprofessional teams can be difficult to start and maintain in practice. Professional training often maintains solo practice as its modality, adding topics related to interprofessional collaboration as elective practice. We have used the stuttering clinic as a way to train counseling and speech-language interns in interprofessional practice and application.

We have observed that to effectively build these teams, it is essential to train our interns on the respective scopes of clinical practice, professional roles and clinical responsibilities of each other’s professions. We also train our students on how to work in teams, how to build relationships based on open communication and respect, and how to understand and use team dynamics that occur during practice. Finally, we reinforce the shared values of both professions — that the well-being of the client is paramount to the purpose of the team.

We have observed that interns typically begin collaborations with thicker boundaries of professional practice and rigid time sharing when interacting with clients. However, after the pair begin to find comfort and understanding of each other’s professional roles, these boundaries begin to wane. Time sharing becomes much more dynamic and less rigid. When intern pairings are working effectively, we see the pair begin to assist each other in their roles and to plan out how they can work together to assist the client during the next session.

To facilitate the interns working together, we teach them specific strategies that are unique to each profession. For example, the speech-language interns learn how to use basic listening skills and practice these skills with the help of their counseling partners. Speech-language interns also learn the foundations of counseling interventions. Specific to the NWCFD-IISC, the interns learn the foundations of ACT. All interns are also taught the practice of meditation and mindful practice, and the principles of acceptance, thought defusion and emotional expansion. Counseling interns learn the foundations of speech-language pathology interventions. Specific to the NWCFD-IISC, they learn about how stuttering occurs, how to assess for stuttering and the social and emotional impacts of stuttering.

All interns in the clinic engage in pseudo-stuttering (fake stuttering) in public and use speech-modification techniques with all clinic participants and the public. Pseudo-stuttering can be used as a therapeutic strategy for PWS to increase acceptance and openness with their stuttering and to increase self-confidence. When the clinic interns pseudo-stuttered and used speech-modification techniques with NWCFD-IISC clients in public, the clients reported that these experiences strengthened the client-clinician relationship.

Our recommendation to counselors and speech-language pathologists who desire to develop collaborative teams is to be intentional about building a professional relationship on the grounds of respect and open communication. The team members should take time to learn about one another’s professions, roles and clinical responsibilities. We have observed during the training of our interns that speech-language pathologists are often focused on outcomes and data collection, whereas counselors are often more focused on process elements and the clinical relationship. It is essential to see both sides of the team as contributing to the overall impact in a unique way. The team members will work to support one another’s strengths and weaknesses.

Counseling interventions

The NWCFD-IISC uses an ACT framework. ACT was chosen because it provides a strengths- and skills-based approach grounded in mindfulness and psychological flexibility. ACT explores human suffering as it relates to psychological inflexibility. Using this framework, PWS learn to more fully focus on the present moment, become more accepting of their thoughts and feelings, and take steps toward acting in alliance with their personal values.

Several studies have supported positive results regarding the efficacy of ACT when applied to stuttering. In addition to this supported efficacy, we think that ACT closely aligns with the philosophy of the NWCFD-IISC. Our philosophy of treatment involves clients and students taking a team approach to understand, accept and effectively manage thoughts, emotions and behaviors related to stuttering. This is accomplished through generalized experiential activities, group education and discussion, and individual and group counseling.

ACT can be understood through the six guiding principles on the ACT hexaflex. These six principles are acceptance, thought defusion, mindfulness, self as context, values and committed action. Investigating how each principle applies, we can begin to understand the process of counseling PWS through an ACT lens.

1) Mindfulness: Clients who stutter often avoid the present moment by judgmentally reviewing the past or worrying about the future. Clinicians can help PWS to connect with the present moment through the use of meditation and mindfulness activities. Encouraging mindful practices can be a goal to incorporate in counseling.

2) Acceptance: PWS often feel like they have no control over their stuttering. Regardless of what they do, a stuttering moment may or may not arise. In these moments, PWS can choose to talk, choose to stutter openly and choose to acknowledge all the thoughts and emotions related to stuttering. Clinicians can help PWS explore acceptance of their thoughts and feelings. PWS do not need to like the thoughts or emotions they experience or enjoy stuttering. However, they can experience their thoughts or emotions as they surface without judgment.

3) Thought defusion: PWS have a tendency to overidentify with their thoughts or feelings, enabling these thoughts and feelings to become mental truths that cause inflexibility within the thought process. PWS may attempt to mentally avoid stuttering or become overwhelmed trying to control their speech. Additionally, PWS may feel certain that other people will reject or harshly criticize them, thus causing them to avoid social contact.

Clinicians can help PWS to explore and express all thoughts — helpful and unhelpful — about their stuttering. By unhooking from the thought or emotion, PWS can experience more psychological flexibility in relation to the context that the thought or emotion is occurring within.

4) Self as context: Individuals often associate with expressions in the form of labels, such as “I am smart” or “I am dumb.” These labels relate to content, not context. Individuals may define themselves in terms of content instead of context to fuse with thoughts and emotions that may be either known or unknown. PWS use self-as-content behaviors to avoid facing the reality of stuttering. PWS may think, “I stutter. That’s all I do. Because of my stuttering, I do poorly in school and never meet new people.”

Clinicians should explore with PWS how these thoughts about self are related either to content or context. Reinforcing flexibility in self-identity is key because it allows PWS to adapt more flexibly to novel situations.

5) Defining values: As described by Jason Luoma, Steven Hayes and Robyn Walser, in ACT, values are defined as “constructed, global, desired and chosen life directions” that can be expressed as adverbs or verbs. When exploring values with PWS, the notion of choice is important to discuss. Choice connotes the flexibility and autonomy they possess in defining what guides their behaviors or life direction.

A common values activity involves the “eulogy exercise.” During this activity, PWS visualize what a close friend would say at their funeral. Clinicians might even direct PWS to write down the values that were expressed during the eulogy: “He was a kind person” or “She was a caring friend” or “He was a compassionate individual.” Clinicians can then discuss these values with PWS and explore how these values are currently manifested and how they can become lost. Building awareness of what values are important in a person’s life can encourage these clients to persist through the difficult times they face.

6) Committed actions: ACT explores the concept of choice in alignment with values-based goals. When clients feel ready to initiate steps either within or outside of counseling, exploration of these committed actions in the counseling session is warranted. For PWS, committed actions could be used by encouraging challenging stuttering situations. For example, PWS may choose to take action directed at speaking situations during dating, during novel social interactions or within work settings. Committed action is the stage of counseling that encourages the synthesis of the tools within the complete hexaflex. PWS learn to engage in a way that is adaptive and flexible to their external and internal worlds.


Counseling PWS can be a rich and rewarding experience. Through our work in the NWCFD-IISC, we have built lasting connections with individuals in the stuttering community and learned how to form strong interprofessional teams that enhanced our understanding of two professions. In working with PWS, understanding the specific population concerns is key to effective treatment. Additionally, collaboration with professionals in the speech-pathology discipline can further enhance treatment experiences for PWS and for all professionals engaged in the collaboration.




Chad M. Yates is a licensed professional counselor and an assistant professor in the Idaho State University (ISU) Department of Counseling. He has served as the mental health coordinator for the Northwest Center for Fluency Disorders at ISU for several years. He helped to develop the acceptance and commitment therapy (ACT) manuals and procedures for clients and clinicians at the clinic and supervises the counselors providing ACT. Contact him at

Karissa Colbrunn is a school-based speech-language pathologist in Pocatello, Idaho. She is passionate about merging the values of the stuttering community with the field of speech-language pathology.

Dan Hudock is an associate professor at ISU. As a person who stutters, he is passionate about helping those with fluency disorders. One aspect of his research involves exploring effective collaborations between speech-language pathologists and mental health professionals for the treatment of people who stutter. He is the director of the Northwest Center for Fluency Disorders. For information about research, clinical or support opportunities, visit

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