Monthly Archives: August 2019

Making it safe to talk about suicidal ideation

By Bethany Bray August 26, 2019

“Counseling is both a science and an art, but that’s really true when it comes to [preventing] suicide,” says Julia Whisenhunt, a licensed professional counselor (LPC). “There’s a lot of solid research out there on the topic, but figuring out the complex constellation of suicide warning signs in a specific individual is an art. It’s based on science, but it’s also an art.”

Recognizing suicidal ideation in clients and meeting their unique needs comes not only from being trained and up to date on suicide prevention and response, but also from a measure of professional intuition, says Whisenhunt, an associate professor and director of the doctoral program in professional counseling and supervision at the University of West Georgia (UWG). Suicide is a complex issue, and counselors must do their utmost to ensure client safety and maintain client trust while asking tough questions that probe people’s lowest moments.

Above all, suicide is a topic that counselors should not tiptoe around or be fearful of, stresses Whisenhunt, a member of the American Counseling Association. Practitioners bear a responsibility to screen for suicidal ideation and to address the topic with sensitivity.

“Most people aren’t necessarily going to directly reach out and ask for help. [They] will communicate distress in other ways, and it’s a matter of whether we’re paying attention,” says Whisenhunt, who routinely conducts suicide prevention workshops and trainings on the UWG campus and surrounding community. “As humans, we tend not to see it. We can’t imagine the people in our lives would think about it [dying by suicide]. If you’re not trained in suicide prevention, you might know something’s off but not fully understand what it is and what the warning signs are. That’s the importance of training — so you can make that connection and know how to support them.”

No population untouched

According to the Centers for Disease Control and Prevention (CDC), suicide is the 10th-leading cause of death in the United States. For many age groups, however, it ranks much higher. Consider:

  • Suicide is the second-leading cause of death among those in the 10-14, 15-24 and 25-34 age groups.
  • Suicide is the fourth-leading cause of death among those in the 35-44 and 45-54 age groups.
  • Suicide is the eighth-leading cause of death among those ages 55-64.

In 2017, the most recent year for which CDC statistics are available, more than 47,000 Americans died by suicide — an average of 129 people each day. These numbers reflect a 33% increase in rates of suicide over the past 18 years, according to the CDC. America’s age-adjusted suicide rate rose from 10.5 deaths per 100,000 people to 14 deaths per 100,000 people between 1999 and 2017.

Statistics are even more dire for certain populations, including military veterans. The U.S. Department of Veterans Affairs (VA) reports that there were more than 6,000 veteran suicides each year from 2008 to 2016. In 2016, the suicide rate among veterans was 1.5 times higher than the rate among the civilian/nonveteran population. According to the VA, an average of 20 veterans die by suicide daily.

Issues related to suicide have grabbed headlines in recent years, not only as news outlets have reported on statistics and trends, but also as notable figures such as Robin Williams, Kate Spade and Anthony Bourdain have died by suicide.

With rates of suicide increasing across geographic regions and almost all ethnic groups, people may reach the conclusion that suicide prevention programming isn’t working or isn’t worth the effort. That simply isn’t true, stresses Jenny L. Cureton, an assistant professor of counselor education and supervision at Kent State University. People often cite outreach programs, crisis hotlines and even signs on bridges as things that interrupted them on their path toward suicide, she says. The National Suicide Prevention Lifeline answered 2.2 million calls in 2018 and a total of 12 million calls in the first 12 years after it was established in 2005.

“When we believe that we can cope and that people care about us, when we have hope and reasons to be here, we can more easily choose life. Great prevention efforts target these goals, and laypersons and professionals alike can target them too, every day,” says Cureton, a member of ACA.

“For the most part, as a society, we understand [now] that talking about suicide doesn’t cause suicide,” Cureton says. “But what we might not understand as a profession is that empathizing with a client’s reasons for wanting to die is not the same as agreeing with them.”

“Empathy and trust are a huge factor in suicide work. Empathizing with a client’s situation is not [the same as] endorsing their suicidal thoughts,” she continues. “You have to balance the client’s reality while acknowledging all the facets of it. Take the time to be with them in the scary, angering and sad places where suicide usually resides. And then say, ‘When you escape this place, even for one moment, what do you find there? What’s a moment that you thought would be the end and it wasn’t? Who was there for you? Can you imagine something shifting even the slightest bit? What does that hope look like?’”

Using empathy to acknowledge a client’s pain helps counselors better understand what the client is experiencing and can inform their work together in counseling to help the person stay safe going forward. “I want to see the world from their eyes so I can help them have the world they want for themselves,” Cureton says. This also demonstrates “that I care about them staying here. I care about them having a life that is so worth living that they live it.”

Exploring risk

Assessing for suicide risk is a vital procedure that should be undertaken with every client. However, forging a bond with the client ought to be the first step that professional counselors take before launching into detailed assessment questions, says Kristin Bruns, an LPC who is an assistant professor in the Department of Counseling, School Psychology and Educational Leadership at Youngstown State University.

Practitioners should also endeavor to understand the client’s full situation before intervening. Bruns acknowledges that this may require counselors to overcome an instinct to take action immediately, especially when clients express thoughts and feelings about killing themselves. But what clients need most in that moment is a practitioner who will listen, Bruns says, not one who reacts or recoils.

“Don’t jump in to assist too soon because the client may shut down,” says Bruns, an ACA member who presented a daylong learning institute on suicide assessment, treatment and safety planning at the ACA 2019 Conference & Expo in New Orleans. “[Demonstrating] empathy and being able to sit with [the client’s] discomfort is critical for counselors to do. … Fully listen to the client’s story to feel what they’re carrying. We have to be human in the [counseling] room. Work against the alarm bells going off in your head.”

When it’s time to move into the questioning phase with clients, Bruns recommends that counselors use an evidence-based suicide risk assessment tool and then stick with it. Practitioners shouldn’t go off of memory, even if they have used the same tool for years, she cautions. Numerous evidence-based suicide assessment and treatment tools are available. Bruns suggests that clinical counselors simply choose one that is a good fit for their style and client population.

As the client is answering questions, counselors can probe for detail, such as how long the client has been experiencing suicidal thoughts and what might have led to those thoughts in the first place, such as a life change or personal loss, Bruns says. It’s also important to ask if those thoughts are constantly present with the client or are more fleeting in nature.

“Don’t tiptoe around the issue,” Bruns says. “Starting with clear language from the beginning makes it easier: ‘Do you want to kill yourself? Have you ever thought about how you would die [by suicide]? Do you have a plan? What would it look like?’ Open and clear communication is important. It’s also an opportunity to educate [the client] on the brain and how it doesn’t make rational decisions in a crisis.”

Bruns says that when asking such questions, counselors should remain sensitive to the client’s needs and presenting issue. “We have questions that we know we need to ask, but at the same time, pay attention to the client and don’t overwhelm them. Put yourself in their shoes. If they’re struggling, be thoughtful about how many questions you’re asking [and] your volume and type of questions,” Bruns says.

Certain clients might be particularly wary of disclosing suicidal thoughts because they fear the revelation could affect their athletic or job status (e.g., college or professional athletes, law enforcement personnel, military personnel). Counselors should ensure that they fully explain the limits of client-counselor confidentiality during the informed consent process but also reassure clients that they won’t be institutionalized or “taken away” — like in the movies or television dramas — for acknowledging that they have or have had suicidal thoughts, Bruns says.

“Don’t buzz through conversations about confidentiality,” she says. “Explain that there’s a continuum [of suicidal ideation]. Just by telling me that you’ve thought about suicide doesn’t mean that you’ll be hospitalized. … If there’s any kind of hesitancy [from the client], don’t just barrel through with questions. Pause and reassess, and pick up on why they’re uncomfortable.”

Suicide prevention literature lists dozens of risk factors sorted by environmental and other factors, including feeling hopeless or helpless; experiencing a stressful life event such as divorce or financial trouble; experiencing prolonged stress from bullying, unemployment or other issues; having a family history of suicide; and experiencing a death by suicide of a family member or close personal acquaintance. (Find detailed lists of suicide warning signs and risk factors at the websites of the American Foundation for Suicide Prevention, afsp.org, and the National Suicide Prevention Lifeline, suicidepreventionlifeline.org.)

Clients who have a suicide attempt in their past are at higher risk for another suicide attempt. Co-occurring issues that put clients at higher risk of suicide include depression, bipolar disorder, a substance use disorder, and other mental illnesses that are untreated or are not being properly managed, Bruns notes.

Probing for details of past suicide attempts can help inform counselors’ understanding of an individual’s current suicide risk, Whisenhunt adds. She recommends asking if prior attempts were planned or impulsive, what means the person used to carry out the attempts, and whether the attempts were intentionally or unintentionally interrupted. “Ask about their thoughts and feelings preceding, during and following [the attempt],” she says. “When it didn’t work, did they feel anger or relief?”

Access to lethal means, such as firearms or drugs, also puts a client at higher risk of suicide. Firearms were involved in slightly more than 50% of nationwide suicide deaths in 2017, according to the CDC. The VA reports that 69.4% of veteran suicide deaths in 2016 involved a firearm.

Firearms can be a polarizing issue, but as part of suicide assessment, professional counselors should not hesitate to ask clients if they have access to firearms, Bruns says. These discussions are an opportunity to talk about brain science and how the human brain doesn’t operate rationally in a crisis, she says. Even if clients say they would never touch a gun, they may make an irrational decision if, during a moment of crisis, firearms are easily accessible or are not secured, Bruns points out.

Whisenhunt discourages counselors from asking clients to rate their suicide risk on a scale of zero to 10 during assessment. “[Clients] can’t rate their own [suicide] risk for a number of reasons. Things may change at any given moment. Life is fluid,” says Whisenhunt, who presented a session on suicide prevention at the ACA 2019 Conference & Expo.

Clinical counselors are more likely to understand the full picture of a client’s suicidal ideation if they also screen for depression, anxiety, impulsivity, major life changes (such as job loss or divorce), past trauma, addiction or substance use disorders, other co-occurring issues, and whether the client has a solid support system, Whisenhunt says. “There’s a huge relationship between interpersonal stress and relationship issues and suicide. We need to look at the whole person, not just the suicidal thoughts,” she says.

Counselors must also resist the urge to try to pin a client’s suicidality to a single cause or reason, Bruns adds. Risk factors often come from multiple areas of life, she points out. “Don’t be too narrow-minded in [the] assessment process. Don’t think that there’s one single cause. … Suicide is complex in nature, and too often it gets oversimplified,” Bruns says.

Safety planning

Once a client’s suicidal ideation is recognized and explored through assessment, the next step is for counselors to design a safety plan with the client, Bruns says. She emphasizes that it is critical to create this safety plan in the same session in which suicidal ideation is identified. Counselors should also make sure that the client takes a copy of the plan home.

Safety planning templates are available online (for example, see the Suicide Prevention Resource Center website at sprc.org) and can serve as an evidence-based starting point, Bruns notes. In addition to including the names and phone numbers of friends, family members and professionals whom the client can contact if in crisis (plus contact information for a 24/7 hotline), the plan lists individualized warning signs that a crisis might be developing, protective factors, and coping strategies to fall back on when things start to escalate. Safety planning is considered a best practice and is preferred over the “no suicide contract” method that counselors sometimes used with clients in years past, Bruns notes.

“This is of paramount importance. [Safety planning] gives them coping skills but also a way to reach out for more help,” Bruns says. “It’s an empowering approach. [Clients] are able to identify their triggers on their own. If they’re able to get to step two and go for a run or use a breathing technique to minimize their suicidal thoughts, it’s empowering to realize that they did that on their own. Or, if that didn’t help, they are empowered to take the next steps” and seek help from someone listed on the plan.

Counselors should also be careful to check in with these clients regularly to ensure that their safety plans are still applicable and working. As Bruns notes, clients’ personal emergency contacts may change over time, as might their triggers and coping mechanisms.

Protective factors

Assessment and a counselor’s “focus on the why” are important parts of suicide work with clients. But equally important, Cureton contends, is exploration of clients’ protective factors. Each client will have a combination of things that can bolster and carry them through low moments. Not identifying or asking about these factors does a disservice to the client, Cureton argues.

“If we don’t explore both risks and what has protected them and kept them alive, we are really missing the whole person,” she says. “Only focusing on lessening risk factors is only half the picture — less than half. For those who have a suicide attempt [in their past], they are still here, and there was something that carried them through. To not explore that, address that, is missing something.”

Cureton urges practitioners to listen carefully when clients talk about their low points or past suicide attempts in counseling. The client might use language such as “I don’t know how I got through that moment.” Counselors should use that as an opportunity to help clients talk through and focus on the elements, large and small, that interrupted them on their path to suicide, she says.

Suicide prevention is both a professional and a personal area of passion for Cureton, who lost her grandfather to suicide when she was in middle school. Cureton co-authored an article with Matthew Fink on suicide protective factors in the July issue of the Journal of Counseling & Development.

Cureton and Fink developed a mnemonic, SHORES, for mental health practitioners to use when identifying and discussing protective factors with clients:

  • S: Skills and strategies to cope (emotional regulation, adaptive thinking and engaging in interests)
  • H: Hope (including goals for the future and ways to meet those goals)
  • O: Objections (moral or cultural objections)
  • R: Reasons to live and Restricted means (motives for staying alive, such as responsibility to family or children, and reducing access to firearms, poisons, medications and other means of suicide)
  • E: Engaged care (receiving care and finding a meaningful connection with a counselor, physician or other medical or helping professional)
  • S: Support (supportive social environments and relationships, including family and caregivers)

Support can also include professional and career connections, political or activist groupings, and other nonfamilial relationships, Cureton adds. She says counselors should explore support systems even with those clients who appear to have a large number of friends. Clients can often feel alienated from friends who have moved or had life changes, such as getting married or having children, she notes.

Cureton acknowledges that the second point, hope, can sometimes seem nebulous. So, in addition to engaging clients in goal-setting and thinking of the future, Cureton directs them to visualize what their version of hope looks like. In session, she sometimes cups her hands together and holds them out to the client, asking the client to describe what, for them, makes up the “ball of hope” she holds in her hands.

Cureton then asks where the client would like to keep this hope. She and the client visualize taking the hope from her hands and “storing” it in the client’s purse, pocket or heart. With younger clients, it can be effective to create a “hope jar” in session or to have them design a room in a video game where they keep their hope, Cureton adds.

Counselors should aim to prompt discussions that help clients envision that circumstances can change for the better in their lives, Cureton says. She suggests asking clients to think of a time when they did have hope and then exploring that answer in more depth together. Alternately, she might ask a client, “Do you dream of a time when you will be self-sufficient and connected?” or “What’s one goal we could set, even if it’s something small?”

“It’s looking into the future and imagining something slightly different,” she explains.

Regardless of how it’s done, exploring protective factors brings a positive narrative and a focus on resilience to a tough topic with dark connotations, Cureton says.

Similarly, Whisenhunt looks for ways to incorporate positive themes into suicide prevention work. She adds a measure of lightheartedness to some of the programs she organizes by calling them “suicide prevention fairs.” With the help of graduate counseling student volunteers, she sets up a series of tables. Participants earn badges as they stop at each table and complete a puzzle or activity to learn about an aspect of suicide prevention. Once they collect all the badges from the fair, participants are eligible for a prize.

“It might sound odd, but you would not believe how many people we get involved. It makes [the topic] more approachable, and people respond,” Whisenhunt says.

When it comes to suicide prevention, positivity and patience can attract interest to a tough subject, she adds. “Know that we might be passionate about it, but it might take the layperson a little while to warm up to talking about it,” she says. “If you’re passionate about something, it comes across. The more I enjoy doing suicide prevention work, the more people enjoy being part of that. I don’t invalidate suicide loss, but I explain that I’m not talking about death and dying. I’m talking about how to save lives. It’s empowering — focusing on hope and the fact that we can do something.”

A delicate subject

Cureton acknowledges that introducing the topic of suicide and suicidal ideation in session can be “prickly.” She prefaces her questions to clients by allowing that it is a touchy subject — but one that is important to deal with.

“I say, ‘You may assume that even if we talk about it, I’ll respond in a negative way, be shocked at what you’re sharing or brush it off because I’m uncomfortable. But none of these things will be true. I’m used to talking about it, and it needs to be covered.’”

When it comes to suicide, counselors need to think both in terms of the individual and systemically, Cureton says. The subject may be even more uncomfortable for clients who come from a culture or religious background that shames or stigmatizes suicide, viewing it as a personal failing or sin. Cureton lets these clients know that it is her responsibility as a professional counselor to learn about their culture and how suicide might be perceived within it.

“If I’ve done that work, it should be easier for me to say … ‘I know that this is an uncomfortable topic to talk about for everyone, but especially in your culture. I know that it might be harder for you to talk about it in here than [it is] for me.’”

She also works with these clients to identify someone from their cultural group with whom they might feel comfortable talking about suicidal thoughts — for example, a pastor or elder perhaps. As a counselor, Cureton says, “I can’t be the only person they talk about this with. It’s important to have someone in their cultural group.”

On the flip side, cultural factors can also influence how counselors view the issue of suicide and clients struggling with suicidal ideation, Bruns notes. As with all issues, it is important for practitioners to put their own attitudes and beliefs aside and to respond to clients with empathy and without judgment, she says.

Elizabeth Hodges Shilling is an LPC and licensed clinical addictions specialist who works as part of a counseling team in the trauma center at Wake Forest Baptist Health Medical Center in Winston-Salem, North Carolina. She also urges counselors to drop any assumptions they may harbor about suicide, especially in connection to client demographics.

“One of the things that is not frequently talked about is [suicide and] older adults. We do see a fair number of [older] individuals who are struggling with both suicidal ideation and substance abuse. We find that older adults at times, in fact, have a greater risk of completing suicide and dying by suicide,” says Shilling, an ACA member. “Frequently, people make assumptions about death with older people or assume that it was an accident or natural [cause]. Keep your assumptions about people in check, especially when it comes to who’s at risk. … It’s not doing that person any good
to assume.”

Whisenhunt agrees and stresses that counselors need to have conversations about suicide with their clients that are free of judgment or expectation. “Just talking about suicidal thoughts and distress can be helpful [for the client]. A lot of people feel a lot of shame about these feelings,” Whisenhunt says. “Be open to talking about suicide without getting nervous and inadvertently shutting down the conversation.”

The long term

Is a client who has experienced suicidal ideation ever not at risk? Bruns recommends checking in with clients periodically, even if they seem to be long past their lowest point. She tells clients that she would rather annoy them with repeated questions about suicide risk than somehow not ensure that they are still safe or not offer them the space to continue talking about it.

Bruns also urges practitioners to be mindful of a client’s triggers and to use clinical intuition to broach the subject, if needed. For example, perhaps a client previously experienced suicidal ideation after a painful break-up with a partner, and now the client is dating again or facing relationship struggles.

At the same time, counselors shouldn’t assume that because a client experienced suicidal ideation in the past that he or she will continue to have suicidal thoughts, Whisenhunt says. Life is fluid, and risk factors may increase, decrease or sometimes change altogether.

“Whatever was contributing in the past might have resolved, but maybe not. For me, a best practice is to screen with all clients at intake and then periodically screen throughout treatment,” Whisenhunt says. “It’s our responsibility to communicate that we can talk about this. We are not afraid of talking about [suicidal ideation], if you need it.”

The silver lining

Cureton acknowledges that suicide prevention work is challenging and can induce fear, even for those who specialize in it or have years of experience. However, as rates of suicide continue to increase across the U.S., counselors have the much-needed skills to address and destigmatize the issue with each client who sits in front of them.

“The unfortunate reality is that suicide is everywhere. It has the potential to be present in any person we are working with, at any point in their life,” Cureton says. “The positive side to this is that anyone can play a role in addressing that — career counselors, school counselors, all practitioners. … The great thing is that we can all do something about this. It’s a misnomer that suicide work is only for certain types of practitioners, such as addictions or clinical mental health counselors. It’s important for all of us to say, hey, we can do something about this.”

 

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Call for help

The National Suicide Prevention Lifeline offers free and confidential support around the clock, seven days a week, at 800-273-8255 or via chat at suicidepreventionlifeline.org.

Calls are routed to the nearest location in the Lifeline network of more than 150 crisis centers across the U.S. Help is offered in Spanish at 888-628-9454 and for callers who are deaf or have partial hearing loss at 800-799-4889.

The Lifeline website also has information on best practices for mental health practitioners, downloadable brochures and other resources.

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For more information on suicide prevention, access ACA’s webpage of resources at counseling.org/knowledge-center/mental-health-resources/suicide-prevention-resources.

CT Online also offers a variety of past articles on the topic, including:

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Suicide, substance abuse and medical trauma

Counseling Today interviewed members of a team of professional counselors embedded in a trauma center in a busy hospital facility in North Carolina. Read more about their work and their insights on the intersection of suicidality and substance abuse in an online exclusive, “Suicide, substance abuse and medical trauma.”

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ACA participates in federal suicide screening panel

Carrie Wachter Morris, an associate professor in the Department of Counseling and Educational Development at the University of North Carolina at Greensboro, represented the American Counseling Association in June at an event titled “Building Robust Systems for Suicide Screening and Treatment Pathways for Youth in Pediatric Settings.”

Organized by the federal Substance Abuse and Mental Health Services Administration, the event’s goal was to inform and shape a guide to suicide screening in pediatric primary care settings. Wachter Morris was the only professional counselor on the event’s expert panel. The audience was primarily composed of medical doctors but also included nurses, social workers and others.

“We talked about a range of things over the two days that we met, including screening instruments, clinic flow, the role of other medical and nonmedical personnel, financing and sustainability,” Wachter Morris says. “Much of what we talked about included the need to really support primary care providers in the process of assessment and referral of youth who are contemplating suicide. … Discussion centered around the importance of appropriate referral and [how] immediately placing a youth who discussed suicidal ideation in an inpatient placement was likely to be counterproductive, unless it was necessary to maintain that individual’s immediate physical safety.”

“This is really where counselors can make a huge difference,” Wachter Morris says. “We can engage with the medical professionals in our community so that they know the resources that we have to support children, adolescents and their families when they are struggling. So many of the [physicians] at the table expressed frustration at not knowing where to connect youths who are in need of support and lacking the time and expertise to intervene on their own. Particularly when coupling this with the industry standard that pediatricians should spend approximately 10 minutes with each patient, it’s easy to see how suicide screening and treatment has not been well-integrated into primary care visits. I spent a good bit of my time educating the medical providers at the table about what counselors are able to do and what a strong support we can be for them. … I also helped advocate for the needs of all our children and adolescents, including the specific needs and risks of those in minoritized communities, and particularly those who identify as LGBTQI+. We had an engaging dialogue about how to promote openness and reduce the likelihood that a youth might feel further silenced.”

Wachter Morris says she came away with an appreciation for the potential for collaboration between professional counselors and pediatricians on suicide prevention.

“Professional counselors have the power to support individuals who are experiencing crisis and trauma, wrestling with mental health issues or experiencing challenging transitions. As a field, we are dedicated to helping people not only survive but also thrive. We have training that pediatricians and family medical providers don’t,” Wachter Morris says. “That was something that really struck me. I’d always thought that because they had rounds in psychiatry that [physicians] had a strong working knowledge of mental health issues and suicide. But that was clearly an assumption of mine that isn’t necessarily reality for every medical provider.

“There are some who are exceedingly skilled, but there are also those who may not ask suicide screening questions for fear of what to do if a child or adolescent answers that they are thinking about suicide. Counselors can be a group that pediatricians’ offices can connect with when they have a child or adolescent who is struggling, not just with suicidal thoughts, but with other challenges that are outside that physician’s scope of practice.”

— Bethany Bray

 

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Contact the counselors interviewed for this article:

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

Letters to the editor: ct@counseling.org

 

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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.

Understanding the gap: Encouraging grad students to work with an aging population

By Neha Pandit August 20, 2019

It often feels like an uphill battle to be attending graduate school, working, sifting through large amounts of data about practicum (and then internship) placements, and weighing options all at the same time. As a graduate counseling student, there are recurrent moments of panic and thoughts of What am I going to do? Where should I apply? and the unavoidable, multifaceted What if … ?

As someone who has advised graduate students, supervised future counselors throughout their clinical training process, and practiced for over a decade myself, I try to break this process down into questions such as: What do you hope to achieve? What interests you? What type of work do you see yourself doing when you graduate? These questions illicit responses that span from the specific (e.g., “I want to work with kids who are struggling with an addiction”) to the more general (e.g., “I want to get experience doing actual therapy”).

Many clinical training directors will tell you that what we less frequently hear is counseling students who say they want experience working with older adults. When I suggest that this is a growing field with extremely diverse opportunities — from setting (hospital, community, private) to format (individual, family, group) — what I often get in return is a perplexed look, a head shake, and a facial expression that seems to suggest anxiety. This is accompanied by a statement to the effect of, “I’m just not comfortable counseling an old person. What could I possibly say to them that they haven’t already heard?”

 

Uncertain about the uncertainty

The reasons behind this uncertainty are not simple. First of all, what does being an “old person” or “geriatric” even mean? Society most often measures these constructs in terms of years. According to the World Health Organization, the beginning of “old age” typically hovers somewhere between 60 to 65 years old, coinciding with average retirement age in many cultures. But even this age range is slowly shifting upward as we live longer and healthier lives. According to the U.S. Census Bureau, in 2017, 15.6% of the U.S. population was 65 or older. By 2030, this number is estimated to grow to 25% of the population. The Stanford Center on Longevity estimates that 10,000 Americans turn 60 every day.

Given the many opportunities to enhance their clinical skills with such a large and diverse population, how can we understand the hesitation that counseling graduate students may show toward working in organizations that aim to provide services to those over 65? Is the hesitation connected to an internal fear of the unknown — growing older themselves or thinking about loved ones aging and not being ready to face those prospects? Or does it involve assumptions made about people based on age? In speaking with students and fellow counseling supervisors, I think it has to do with a combination of those two reasons.

We all get nervous about working with unknowns, of course. Applied to this situation, the origins of this uneasiness seem obvious: Graduate students have all experienced being children before, but few of them have experienced being old. When a shared reference point is not available, assumptions are all too often generated from stereotypes. The same holds true with words such as “old,” “geriatric” and “elderly.” The problem is that the almost automatic images associated with these descriptors — and with presumptions about fragility, sickness, and resistance to change — are not appropriately reflective of older adults in general.

Given the inevitability of aging and the astounding need for more counselors with geriatric training and experience, I often wonder what we can do to challenge such inhibitions and encourage more students to pursue opportunities to work with older adults.

 

Challenging myths

It is vital to this discussion to debunk age-related myths. This involves challenging the veracity of automatic links and images that students may generate related to the mental and physical well-being of aging adults.

One way to accomplish this is by discussing the basic statistical concept that the variability of differences within a group is much greater than the variability between groups. Said another way, it is more likely that a graduate counseling student will have more in common with an older person than it is for a group of older adults to have a lot in common with each other. This concept should already be a learning objective that is core to any multicultural counseling class. Ensuring that graduate counseling classes that focus on matters of diversity also include exploration of what aging does and does not mean could go a long way toward breaking down uncertainty that is based in incorrect automatic images and assumptions rather than in reality.

Scientific and technological breakthroughs mean that what once seemed to be inevitable byproducts of the aging process are no longer homogeneously applicable. Here are two examples of myths with associated reality checks:

 

Myth: Old people are fragile and are probably ill.

Reality: Some diseases, infections and conditions that were not understood or treatable 50 years ago are now completely preventable or treatable at any age. The National Institute on Aging states that the average age of onset of many chronic illnesses (for example, arthritis and heart disease) has increased incrementally by 10 years over the past 80 years. This means that people are staying healthier for longer and have freer will to control environmental factors that can facilitate good health.

 

Myth: Old people are set in their ways and don’t want to change.

Reality: Personality characteristics usually remain stable over time. Someone who was generally resistant to change over the course of his or her life is likely to remain resistant to change. However, the converse is also true: Someone who generally welcomed change over the course of his or her life is likely to continue to welcome change.

 

Getting personal

Normalizing the fear of the unknown, identifying experiences that may affect this, challenging the rationality of assumptions around aging, and having frank discussions about the universality of “experience” are all pivotal to encouraging graduate students to work with an aging population.

By “universality,” we are not just referring to the inevitability that, with luck, we will all get older. Rather, it refers to the reality that we are all subject to similar challenges and emotions that can arise at any point in our lives. For example, relationship difficulties, depression, anxiety, trauma, illness and loss are life challenges that a 5-, 25- or 75-year-old can face. Therefore, a 5-, 25- or 75-year-old could benefit from treatment.

Erik Erikson recognized this lifelong process of continuous development, growth and reflection through the “integrity versus despair” stage in his theory of psychosocial development. According to Erikson, around age 65, individuals begin to profoundly reflect on the meaning in their life thus far. Someone who is able to find this meaning and look back on life with few regrets moves toward integrity. If, on the other hand, individuals feel they have wasted their time and are full of regret, they will be more prone to despair. Meeting the developmental needs of older adults as they negotiate this critical phase elucidates a common clinical issue that both current and future counselors will always face: perception of meaning in life.

We want our counselors-in-training to mature in their reflective capacity skills and to strive to understand internal variables that they may bring into sessions. By the time they are in the classroom with us, most graduate students have had the experience of seeing loved ones age, and those who have not could be anxious about the certain reality of having this experience at some point in the future. This gives counselor educators and supervisors the opportunity to explore with students how their reactions to these inevitable realities are collective in nature and how they are shared by many people, regardless of age. A counselor-in-training with good reflective capacity can harness the associated emotions and funnel them into an invaluable therapeutic tool: empathy.

 

Recommendations and tips

As mentioned earlier, the diverse options for working with older adults better enables us to match student interests with appropriate placements. I had a student who was interested in getting clinical experience with family therapy and older adults in hospital settings. The student was able to find a placement in a hospital working with families in which one of its members had been newly diagnosed with Alzheimer’s disease. Another student had strong interest in getting experience working with addictions. The student was able to find a placement at a methadone clinic and was assigned a good caseload of older clients who were in recovery. My point is to communicate to students that the variety of placements available for working with older adults mirrors the diversity of today’s older adult population.

The passage of time inevitably brings change and, with that, different challenges and fluctuations. As counselor educators and supervisors of future practitioners, it is our responsibility to challenge and prepare graduate students to tackle these issues. Whether it’s a student seeking guidance or a person seeking counseling, assisting in increasing their reflective capacity, adaptation or coping with these challenges and changes is core to what we do as educators and practitioners. Regardless of how old the person sitting in our office or classroom is, engaged learning can happen in countless forms, as can growth through stepping out of one’s comfort zone.

 

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Neha Pandit is an assistant professor at Robert Morris University, working mainly in the master’s counseling psychology program. She also has more than 15 years of clinical experience and is currently working at a practice in Wexford, Pennsylvania. Contact her at pandit@rmu.edu.

 

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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.

Looking back, looking forward

Compiled by Jonathan Rollins August 15, 2019

Simone Lambert recently completed her term as the American Counseling Association’s 67th president, handing over the reins to new ACA President Heather Trepal on July 1. Shortly before leaving office, Lambert agreed to answer a series of questions from Counseling Today reflecting on her experience as ACA’s top elected leader. Her answers give context to some of the major happenings and challenges within the association and the counseling profession as a whole and provide insights into possible future directions.

 

When you look back on your past year as president of the American Counseling Association, what are you most proud of?

Without any hesitation, the single area I am most proud of is our advancement toward national portability. The ACA Governing Council prioritized the strategic initiative of “1.1 Working to advance and ensure that licensed professional counselors enjoy seamless portability of their licenses when: moving to other states; practicing across state lines; and engaging in tele-counseling” for this year and next.

In October 2018, after careful deliberation, Governing Council unanimously approved funding for the development of a professional occupational interstate compact for professional counselors. We thoroughly vetted and contracted with the National Center for Interstate Compacts, an arm of the Council of State Governments. The ACA Portability Task Force provided invaluable expertise and asked critical questions. ACA leaders and staff do not spend membership dues lightly. Thus, the contract was meticulously reviewed and revised to ensure optimal outcome.

While national portability will be a multiyear process, ACA is making a massive investment that likely will improve counselor workforce retention, including for military spouses, and increase access to mental health services. The interstate compact is a policy vehicle that furthers the work that began years ago with the Building Blocks to Portability Project of the 20/20: A Vision for the Future of Counseling initiative and the adoption of the ACA licensure portability model. 

In which specific areas do you feel like the association as a whole is gaining positive momentum?

Under the guidance of CEO Rich Yep and the executive team, the association has been transforming into a modern association looking ahead at how best to meet the needs of current and future ACA members. The internal, behind-the-scenes transformation has been extensive. We, as members, see snippets of this with such activities as being able to access the Journal of Counseling & Development and Counseling Today on our phones and being able to readily search and find clinical resources on our website.

As leaders, we see the revolutionary impact of our robust strategic framework that Governing Council approved in April 2018. Implementation of the strategic framework has had widespread impact on the association, including how staff workplans are developed, what staff and leaders prioritize across the association, and how we evaluate the organizational performance. Leaders also revamped our Governing Council agenda to include time for generative, strategic and operational discussions. The combination of the revised agenda format and the strategic framework has allowed Governing Council to move forward in collective thought leadership.

What issues took up most of your time or received a substantial amount of focus from you this year? Why were these issues so important?

The ACA president is a spokesperson for the association. I wholeheartedly jumped into this role as a way to advocate for the counseling profession and those we serve. Another priority initiative this year and next is “3.2 Raising awareness among the public and consumers about the benefits provided by the counseling profession.” In addition to providing keynotes and attending ACA branch and division conferences, I presented at the Mental Health America and the Time to Thrive conferences. I also had the privilege of advocating and interfacing with staff from the National Institute of Mental Health (NIMH), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Disease Control and Prevention’s Division of Adolescent and School Health, the Department of Education, and national and state legislators. These efforts were important to increase knowledge of our profession among decision-makers.

Often this year, I found myself to be the only licensed professional counselor in the room. I gleaned a few things from that experience. First, Shirley Chisholm’s guidance of “If they don’t give you a seat at the table, bring a folding chair” resonates more than ever. If we want clients and students to receive psychoeducational materials that are developed from a strength-based wellness perspective, we need to be at the table. If we want to be included in federal grants and Medicare reimbursements, we need to invite ourselves to the table.

Second, just like the Whos in Horton Hears a Who! we need a megaphone to collectively say, “We are here!” The American Counseling Association, including staff, leaders and members, is that megaphone. To raise awareness with the public and policymakers, we proactively need to state that we are part of the solution to the mental health workforce shortage. To obtain parity of status with other professions, we need to increase our visibility among federal and community partners.

In addition to meeting with our sister counseling organizations throughout the year, I met with representatives from the American Psychological Association (Division 17), the American Art Therapy Association, the World Health Organization, the United Nations (U.N.) Department of Public Information and nongovernmental organizations, as well as the Human Rights Campaign, the Born This Way Foundation and many other community agencies.

In addition to Skyping into doctoral counselor education classes and attending a residency with master’s-level interns from all over the world, I was honored to speak on behalf of the profession to those in the media, including venues such as NPR, Brit + Co, Time magazine, The Deseret News, USA Today and MEA Worldwide. I was interviewed on the Sirius XM Radio station Doctor Radio with host Dr. Michael Aronoff. With the guidance of the Promoting Mental Health and Averting Addiction Through Prevention Strategies Task Force and the expertise of ACA staff, I even did a video for ACA’s Instagram and a Twitter chat during National Prevention Week of Mental Health Awareness Month.

Seizing on opportunities to say “we are here!” in ways that promote the counseling profession as a resource is critical to not only increase awareness, but also to join with partners to decrease stigma and increase access to counseling services. 

Were there any issues that you developed a new appreciation for or that you gained a substantial amount of new knowledge about throughout the year?

In addition to trauma-informed care, I have a whole new appreciation for intersectionality. People are complicated and multifaceted. Attending events like the launching of Project Thrive and the SAMHSA Voice Awards, I heard amazing stories of resiliency related to people who had a mental health or substance use disorder, physical health issues or were from marginalized communities. Approaching counseling practice and advocacy with lenses of trauma-informed care and intersectionality within this sociocultural political climate is challenging and requires strong coalitions of professional associations, community agencies and government partnerships where possible. To assist our champion legislators, we as a profession need to produce more large-scale research studies that demonstrate the effectiveness of professional counselors.

Internally, we need to follow other professions in setting safeguards to assist counselors who have relapsed with their own substance use disorders or who are having mental health challenges. The ACA Code of Ethics discusses gatekeeping and counselor impairment, but we as an association have just begun to have conversations about policies related to member impairment as a larger issue. Other professional associations have resources to monitor members who are unwell or whose behavior is harming the profession. Counselors are not immune to mental health struggles, and we can actively address the issue for the betterment of our members and profession.

As ACA president, you spent a significant amount of time traveling and meeting with other counseling professionals and counselors-in-training. What did you learn from those conversations? Did a particular concern or question get voiced repeatedly?

Counselors have a strong professional identity, yet we still struggle with recognition of our profession within the mental health workforce. Beyond raising awareness, the third strategic initiative priority for this year and next is “1.2 Working to ensure equitable, consistent and adequate reimbursement for appropriately educated, trained and licensed professional counselors in all practice settings.”

After navigating undergraduate and graduate degrees, undergoing extensive post-master’s degree supervision, and passing credentialing exams, professional counselors across settings want to make a livable wage. They worry about competing with life coaches, who have less training but charge more. The Counselor Compensation Task Force found much variability in reimbursement rates, and counselors hope to have parity of status with other mental health professionals to have comparable reimbursement rates. Counselors also want to work in interdisciplinary teams, but they need other professions such as medical doctors, psychiatrists and clinical psychologist to recognize the value added when including professional counselors across settings to the treatment team.

Another huge challenge for counselors is student loan debt, which impacts counselors’ ability to afford to stay in the profession, especially through those prelicensure years. Engaging in professional association membership and participating in professional development on top of licensure application fees, supervision expenses and liability insurance coverage is challenging for those with higher student loan debt, which is often women, a large percentage of our counseling profession. 

How did your own perspective change in the year you served as president? Is there anything that surprised you?

Having met with all of our sister organizations, my bird’s-eye view of the profession has informed my perspective about how our profession is in the midst of a major transition. Over the past few years, we have seen turnover of long-serving staff at the helm of Chi Sigma Iota (CSI), NBCC, CACREP and the Association for Counselor Education and Supervision. Even our own David Kaplan, ACA’s chief professional officer, retired this spring after 15 years.

We have seen CACREP and the Council on Rehabilitation Education merge and alternative accreditation proposed by other associations. The American Association of State Counseling Boards has transitioned from an independent organization to being managed by the Center for Credentialing & Education, an affiliate of NBCC. In addition, two large ACA divisions, the American School Counselor Association and the American Mental Health Counselors Association, decided to disaffiliate from ACA. Change is difficult for all of us, yet with change comes opportunity. For instance, ACA can now fully serve and strongly advocate for professional counselors who work in schools and community agencies. ACA continues to maintain collaborative relationships with our sister organizations. The concerted wraparound response to the closure of Argosy University is an excellent example of how ACA, CACREP, CSI and NBCC each addressed the part of the crisis within their purview. 

This year, I attended two International Association for Counselling (IAC) conferences. I was incredibly surprised to learn how many countries look up to ACA as a model professional association. We are leaders in the international community. Likewise, there is much to learn from other counseling professional organizations that have dealt with similar issues. Interestingly, there seems to be a developmental curve for counseling organizations whereby we are one of the older counseling organizations. Then there are countries such as Uruguay, which is developing its first counseling degree program. None of the countries I met with had as complicated of a licensure situation as we do. We are unique with our unique licensure laws in 50 states plus U.S. territories.

After attending global conferences of the U.N., IAC and NIMH, a few startling themes stood out. First, there are not enough of us. There is a national and international mental health workforce shortage. We need to work to reduce barriers and obstacles to “scale up.” Second, there are forces beyond our control, such as climate change, that will increase the need for counselors to assist with issues related to migration and loss of livelihood as lands, resources and industries are subsumed. Third, there will be dramatic shifts in the workplace as technological advances and artificial intelligence necessitate retraining many people. School and career counselors will play an instrumental role in readying the next generation for jobs that have not yet been created. Finally, we will see increased telehealth and integrative approaches to mental health.

Where do you see things heading with ACA and with the counseling profession as a whole? What are some of the major issues or challenges that the association and profession will need to address in the coming years?

A major challenge of the profession is diversification of our workforce. Another item in our strategic framework is “3.1 Building a diverse, inclusive and engaged pipeline of counselors who will serve well into the 21st century.”

I attended a screening of Personal Statement, which followed three high school students who were from marginalized and underrepresented populations. The additional obstacles that these students faced were seemingly insurmountable. If we are going to have a more diversified counseling profession, we need to start advocating for people of color and diverse cultural backgrounds much earlier in their academic career paths. As these students make it to counseling graduate programs and leadership positions, we need to provide mentoring and support to increase retention and ensure that their voices are at the table when policies are being made. The message of “nothing for us without us” was mentioned to me in multiple venues this year, and I strongly believe that those with privilege need to listen to and advocate with those from diverse backgrounds.

Having diversity within the counseling profession is critical so that clients have the option to see counselors who are representative of their own backgrounds. In addition, there are societal stressors impacting clients that may impede on therapeutic progress. For instance, poverty, income inequality, education and other systemic issues could be barriers to accessing services. While counselors have the ethical responsibility to advocate, we cannot solve all of the world’s problems on our own. We need to work with other professions and stakeholders, including those outside of mental health, to tackle issues that prevent clients from seeking counseling services.

To further the ideas of breaking down silos, viewing the client from an intersectional perspective, and working across specialty areas, the structure of ACA in some ways restricts such collaboration. There are many entities within the ACA structure, including regions, divisions, branches, task forces, committees, interest networks and ACA Connect communities. Some of these entities are autonomous, such as divisions and most state branches. Other entities fully consist of ACA members, yet members may not know how their entities’ charges are related to another entity. Thus, the structure of ACA could become streamlined to increase efficiency in operational costs and content development. We have had many conversations, and I anticipate there will be many conversations to come.

Ultimately, we need some guidance from an association architect to reconfigure our professional house built in 1952. It’s time for serious structural renovations to help us be more productive as a whole. Imagine a professional home where subject matter experts have a structure to pool together best practices and evidence-based strategies for ACA members to address intersectionality in session and advocate on related legislation.

Looking back with all of the experience and information that you have now, is there anything you might do or approach differently if given a second chance?

If I had a do-over, I would have spent more time with our ACA committees, which are the workhorses of our association. In every meeting I attended and every email I read, it was apparent that our committees and task forces consist of incredibly dedicated and passionate volunteer leaders. For instance, the Human Rights Committee has recently developed advocacy statements about gun violence, climate change, transgender and nonbinary issues, indigenous people’s rights and concerns, and judicial and punitive disparity.

In hindsight, there could have been additional bridging and connecting of the committees with other committees/task forces and other ACA entities. One example was the leadership campaign that took place at the ACA Conference in New Orleans, whereby the Branch Development Committee and the region chairs worked to identify potential counseling leaders. Special thanks goes to the region leaders, CSI and the Association for Multicultural Counseling and Development for allowing recruitment of potential volunteers to take place at their venues.

Any words of advice or guidance for new ACA President Heather Trepal?

My hope is that President Trepal stays focused on our mission: “Promote the professional development of counselors, advocate for the profession, and ensure ethical, culturally inclusive practices that protect those using counseling services.”

Our counseling association is unique from all others. We include 18 divisions that represent specialties and settings across the profession. When ACA makes decisions, we do so understanding our responsibilities to all of our members. President Trepal is well-supported by an incredibly talented staff and deeply committed group of leaders. She is not in this by herself. Based on my lessons learned, I encourage her to ask and accept help as needed, listen and learn, share her expertise, and strengthen ACA by collaborating with internal entities of ACA and external partners.  

In what ways will your time as ACA president influence your work as a counselor educator or clinician moving forward?

The amount of hardship and pain that I heard about throughout the year could be very disheartening, especially in our polarized times. However, I am optimistic from seeing the work of so many counselors, allies, researchers, advocates, policymakers, staff and leaders who are working in the trenches to promote mental health.

As a counselor educator and mentor, I want to assist learners and emerging leaders to identify tables where their voices need to be heard. As a professional counselor, I want to focus my energies on decreasing stigma, increasing access to care, encouraging wellness, and helping clients and policymakers hear us say, “We are here!”

 

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Jonathan Rollins is the editor-in-chief of Counseling Today. Contact him at jrollins@counseling.org

 

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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.

From Combat to Counseling: Characteristics of the military affiliated population

By Duane France August 13, 2019

When we talk about serving the military population as counselors, it would be easy to think that we’re talking about a group of clients who are similar and homogenous. It’s true that there are many common factors among those who serve in or are affiliated with the military, but there are a large number of differences too. Age, ethnicity, gender, period of service, full time or part time, combat or not — all of these factors have their own impact on the experiences of military-affiliated clients.

Because my goal is to help my fellow counselors understand how to address the unique needs of this population, it might be helpful to expand a bit on what I term SMVF: service members, veterans and their families.

 

Service members

This segment of the SMVF population seems easy to define: It includes anyone who is currently serving in the military. That broad definition is accurate, as far as it goes, but it is also deceptively simple.

When talking about a service member, it is important to understand a number of different things, including which branch of service they are in. Whether a client is currently serving in the Army, Air Force, Navy, Marine Corps or Coast Guard is an important distinction. Each branch of the service has its own sub-culture, a different rank structure, and vastly different experiences.

And even in each branch of service, there are subcultures within the subculture. Does the client serve in the Air Wing of the Marine Corps? Which occupational specialty does the client hold in the Army: Infantry? Military intelligence? Logistics and supply? Each of these sub-branches has its own unique outlook and experiences.

Even the current location of service helps to further define service members. For instance, there is a difference between the experiences of a Marine stationed at Twentynine Palms, California (not so great), and one stationed at Marine Corps Base, Hawaii (pretty great). Or the experiences of a soldier stationed at Fort Polk, Louisiana (one of the least desired duty locations), compared with a solider stationed at Fort Carson, Colorado (among the top five most desirable duty locations).

Currently serving military clients also include those drilling in the National Guard and Reserve. Each branch of the service has a Reserve force, and each state has a National Guard and Air National Guard unit. Typically, currently drilling service members in the National Guard and Reserve attend a weekend drill of anywhere from two to four days once per month and participate in a two- to four-week annual training each year.

Not all currently serving military members have equal access to mental health care. National Guard and Reserve service members, for example, have access to Department of Defense mental health professionals while they are on weekend drill or annual training, but not for the rest of the time. And the availability of mental health services, both on base and off base, differs with each duty location.

 

Veterans

Similar to the term “service member,” the term “veteran” is also deceptively broad. Title 38 of the Code of Federal Regulations defines a veteran as “a person who served in the active military, naval, or air service and who was discharged or released under conditions other than dishonorable.”

Although that may seem fairly straightforward, one glaring omission is former National Guard or Reserve service members who were never activated for full-time military service. This exclusion means that someone who enlisted in the military and, at minimum, participated in basic and advanced military training but did not serve on active duty is not considered a veteran.

The veteran community is further subdivided depending on whether the individual served in combat. There are currently four broad categories of combat veterans. The first is World War II and Korean War veterans, many of whom are in their 80s and 90s today. The next generation, the Vietnam veterans, are over age 65. The youngest veterans of the Gulf War (Operation Desert Storm) are in their 40s. Where things get complicated is with the fourth category of veterans. The senior leaders of the global war on terror, who are considered post-9/11 veterans, served in Vietnam, whereas the youngest members of the post-9/11 generation weren’t even born before Sept. 11, 2001.

Of course, that leaves a large number of individuals who served in the military but did not deploy to combat. They are identified as veterans, of course, but in the eyes of some (including, in some cases, their own view), they are not considered “real” veterans. These include people who served in the post-Vietnam era in the 1970s, Cold War veterans who served in the 1980s, and the post-Gulf War veterans who served in the 1990s. Regardless of whether people deployed to combat, however, the military is an inherently dangerous place.

According to a 2015 Congressional Research Service report, 2,392 active-duty service members died in 1980. Compare that figure to the total number of active-duty deaths in 2010: 1,485. There were two major conflicts in 2010, Operation Iraqi Freedom (Iraq) and Operation Enduring Freedom (Afghanistan). There were no conflicts in 1980. The reasons for this higher active-duty mortality rate in 1980 are speculative, but they likely have to do with advances in safety protocols and medical treatment that have increased the survivability of catastrophic injuries. Of course, if more members of the military population are surviving catastrophic injuries, then it means there are likely more individuals dealing with the psychological impacts of those injuries — which is another area where we can help as counselors.

The veteran population is further segmented by the military subcultures mentioned earlier, which are influenced by factors such as time, location and branch of service. This goes to show that while we consider the word “veteran” to be a descriptive term, it covers a very wide area.

 

Military family members

The designation for the final portion of the SMVF population, military family members, can also be deceptively broad. My wife and I married after my deployment to Bosnia, and she was with me for more than three-quarters of my career. She and my children experienced four of my five deployments in a very different way than I did. They also endured hardships that were significantly different from mine, yet no less challenging.

Being a military spouse is not easy. My wife and I lived in eight different houses in our first nine years of marriage. Three of those years were overseas, and all of them were away from where we both grew up. The stress of constant movement, of nights alone and nights together, can be considerable.

On top of that, you have military brats — the children of those who served. I once had a conversation with my son about where he thought he was “from.” Children of service members, especially those who served significant time in the military, aren’t really “from” anywhere. Many people have roots in a place where they have family; they can point to a childhood home when they go back to visit. For instance, I am from St. Louis, and my wife is from Knoxville, Tennessee. But my kids were born in Germany, started school in Maryland, and have lived in Colorado for most of their lives — but they don’t consider themselves “from” any of those locations.

What further complicates the designation of military spouses and children is that it is used only to describe those who were with the service member while they were serving. My father was a veteran of the Vietnam War, but I wasn’t born until three or four years after he returned home. I never knew what he was like before combat. I certainly know the impact that combat had on him, however, because I saw it for 40 years.

Many veterans — and I’m using the term in its most broad and inclusive form — marry and start families after their military service has concluded. A spouse who was not with the veteran when that person was in the military has little to no understanding of the unique aspects of military life and culture. That spouse certainly experiences the aftermath, however, as does the veteran’s children. My wife was with me while I was serving in the military, so she lived it too. Thus, when I retired, she already had a frame of reference about military life. By the grace of God and my wife’s immense patience, we remained married after I retired.

Finally, when we consider the military family, we should also include parents and siblings. My mother and sisters experienced my military service — and that of my brother, who is also a combat veteran of both Iraq and Afghanistan — in a very different way. And that circumstance brings up an entirely different dynamic: When I left Iraq, my brother was enlisting in the military. Eight months later, he was stationed in the same combat zone I had just left. Less than two years later, he and I were in the same combat zone at the same time, in different locations.

Picture two brothers, one coming in from out of town, who decide to grab some breakfast together. They catch up on what’s happening, and then the in-town brother introduces his out-of-town brother to some of the folks he works with. Only, the out-of-town brother arrived on a Blackhawk helicopter, and the breakfast was at the dining facility on Forward Operating Base Shank, Afghanistan.

To further expand the concept of the military family population, we need to consider those family members who have lost their service member. Parents, siblings, spouses and children of service members who died in combat are called Gold Star families. Those family members of veterans who have died by different means aren’t called anything, but their loss is just as great.

 

Understanding the diverse SMVF population

As this article probably makes evident, talking about someone who is serving or has served in the military, or that person’s family, is not as easy as it might seem at first. The differences between this generationally, geographically, culturally and experientially diverse population may seem large. It is important to understand, however, that a common thread — military service in its many forms — still binds them together.

 

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Read the first From Combat to Counseling column.

 

Duane France, LPC

Duane France is a retired U.S. Army noncommissioned officer and combat veteran who practices as a licensed professional counselor in Colorado Springs, Colorado. He is the director of veteran service for the Family Care Center, a private outpatient mental health clinic specializing in service members, veterans and their families. He is also the executive director of the Colorado Veterans Health and Wellness Agency, a 501(c)3 nonprofit that is professionally affiliated with the Family Care Center. In addition to his clinical work, he writes and speaks about veteran mental health on his blog and podcast at veteranmentalhealth.com. Contact him at duane@veteranmentalhealth.com.

 

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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.

Client suggestibility: A beginner’s guide for mental health professionals

By Jerrod Brown, Amanda Fenrich, Jeffrey Haun and Megan N. Carter August 12, 2019

In the context of mental health treatment, suggestibility refers to a client’s vulnerability to accepting information provided by a third party as true, regardless of its veracity. This can result in the client providing inaccurate guesses or statements in a verbal, nonverbal or narrative format. Influenced by a range of individual, psychosocial and contextual factors, the client may be convinced that events unfolded differently than they actually did or that events that never took place actually occurred.

Such behavior is often encountered when clients are uncertain about what happened or what is true, lack confidence in their own memories or ability to understand, or are unable to discriminate between what is real and what is not. As such, suggestibility can profoundly limit a client’s capacity to navigate the various stages of the mental health system.

Suggestibility is a complex and multifaceted phenomenon that mental health treatment specialists rarely take into consideration, largely because of the lack of research on it and the limited availability of training opportunities on the topic specifically tailored for these professionals. The research that has been conducted is largely circumscribed to the fields of criminal justice, forensics and the law, where it is well-established that clients who are more suggestible are more likely to provide unreliable eyewitness accounts, spurious alibis or even false confessions to crimes.

Across mental health treatment settings, suggestibility may result in inaccurate diagnoses and ineffective or problematic goal and treatment plans. Given the importance of this topic, we aim to briefly describe the phenomenon of suggestibility within the context of clinical interviewing, assessment and treatment planning. We will also suggest future directions that may assist mental health professionals in addressing this threat to effective clinical decision-making.

Minimizing suggestibility risk in clinical interviews

Certain forms of questioning can increase the likelihood of suggestibility. A suggestive question is one that implies a certain answer, regardless of the client’s actual perspective. Such questions intentionally or unintentionally seek to be persuasive, often by using wording that excludes other possible answers. For example, asking “Where did your father hit you?” instead of “What happened with your father when you got home?” is leading. It promotes a response that would affirm the interviewer’s hypothesis that a physical assault took place and largely excludes the possibility that no altercation occurred.

Questions framed in a negative manner also can have a suggestible impact and are confusing to the client. For example, asking “Didn’t you want to run away?” rather than “Did you want to run away?” is biased in that it may make the client feel guilty for not saying that he or she wanted to run away.

To avoid asking suggestive questions and to lessen the likelihood of receiving false responses from clients, consider using the following strategies:

1) Use open-ended questions while avoiding or minimizing the use of forced-choice and either-or questions.

2) Allow the client to speak in his or her own words, and avoid interrupting the client.

3) Do not assume that you know what the client is trying to say when he or she is unable to fully convey his or her ideas.

4) Accept “I don’t know” responses as potentially valid.

To further illustrate this point of decreasing suggestibility within the context of clinical interviewing, mental health professionals should try to avoid the following approaches when questioning clients:

  • Use of closed-ended questions
  • Giving an impression that implies the client is providing the wrong answer
  • Implying that a certain answer is needed or required
  • Leading questions
  • Misleading questions
  • Negatively worded statements
  • Persuading the client to change his or her response
  • Pressing the client for a response
  • Rapid-fire questioning
  • Repeated lines of questioning
  • Biased statements
  • Subtle prompts

How often questions are asked may also have a suggestive impact. Clients may perceive repeated questioning as a sign that they have not responded in a manner that the counselor deems “correct” or acceptable. Indeed, repetitive lines of questioning in which the client is asked about details of events that either did not happen or that the client does not remember well may result in the unintentional formation of false memories or confabulation (i.e., filling in memory gaps with fabricated memories or experiences).

Asking more general questions about an incident (e.g., “Tell me about what happened at the park”) and then later following up with related questions (e.g., “How often do you go to the park?”) has been found to be a useful method for verifying or clarifying information that might appear to be inconsistent or illogical. Regardless of the questioning style, however, it is advisable to allow clients as much time as they need to respond to questions and to verbally reinforce that they can take their time when answering questions.

In addition to questioning style, the counselor’s nonverbal behaviors, including facial affect, gestural affect and intonation, both before and during the interview, may increase the likelihood of suggestibility and threaten the validity of the information elicited. An example of facial affect could be smiling when a client is providing certain answers but not others. A gestural affect might include leaning forward when a client is providing certain answers but not others. Intonation as a means of nonverbal communication could be providing feedback using upward inflection when a client provides certain answers but downward inflection when he or she provides others. These nonverbal, and often unintended, means of communication are forms of both positive and negative feedback that can shape a person’s responses and increase the risk of suggestibility.

The context of the interview can also affect the likelihood of suggestibility. For example, false reports are more likely if an interview is conducted in a stressful situation (e.g., having an appointment with a therapist immediately following a family conflict). Environmental factors (e.g., a small room without windows or air conditioning on a hot summer afternoon) can also be influential. Providing clients with frequent breaks and avoiding very long clinical interviews is encouraged, when possible. The time between the occurrence of an event and the interview that focuses on the event can also influence suggestibility because clients can become more confident in the accuracy of their false accounts over time. Context within the realm of a clinical interview can include any of the following either prior to and during the actual interviewing process:

  • Body language of the counselor
  • Duration of eye contact from the counselor
  • Environmental distractions (lighting, noise, temperature, etc.)
  • Length of the interview
  • Pace of the interview
  • Tone of the counselor’s voice

Mental health professionals should also take into consideration personality and social characteristics that can influence suggestibility. These may include tendencies toward confabulation, acquiescence, memory distrust, low confidence, desire to please, extreme shyness and social anxiety, avoidant-based coping strategies, fear of negative evaluation, lack of assertiveness, attachment disruptions, fantasy proneness, and psychosocial immaturity (e.g., irresponsibility and temperament). Professionals should also consider cognitive factors, including executive function and memory-related problems (e.g., short-term, long-term and working memory), intellectual limitations, diminished language abilities, and deficits in theory of mind (the ability to understand mental states in oneself and in others).

Preparing for and debriefing from the interview

Understandably, many of these characteristics initially present as invisible, meaning that clients who are highly suggestible may not overtly appear as impaired or vulnerable. Clinicians would benefit from screening for such traits in the initial interview with new clients to determine the prevalence of traits that are likely to contribute to suggestibility. Specific screening tools for suggestibility, such as the Gudjonsson Suggestibility Scale, can help clinicians in determining a person’s level of suggestibility. This will also assist clinicians in understanding how best to proceed as it relates to interviewing techniques and treatment planning to account for an individual’s level of suggestibility.

False or misleading information can have a negative impact on diagnostic accuracy and treatment outcomes. Accordingly, it is important that mental health professionals not only conduct interviews properly but also prepare for and debrief from them properly. Prior to beginning an interview, counselors are encouraged to review client records (psychological testing, mental health records, criminal justice records, etc.) that may reveal a behavioral pattern of suggestibility and provide a resource for corroborating a client’s statements. Cross-referencing this information with information obtained from collateral informants is also recommended when appropriate. The importance of awareness of one’s self throughout the interview is an important factor for reducing the risk of suggestibility. This includes monitoring one’s verbal and nonverbal communication that could provide feedback to the client regarding potentially desirable versus undesirable responses.

It’s worth noting that some special situations may require clinicians to be more aware of their questioning style and require adaptations and flexibility on the part of the clinician to minimize suggestibility. For instance, those working in correctional and jail settings should consider how suggestibility presents among incarcerated populations, to include those with mental health needs and low intellectual functioning. Substance use is another variable that can have adverse effects on the accuracy of the information obtained during a clinical interview. Furthermore, when interviewing children or adults with neurocognitive and neurodevelopmental disorders, extra precautions may be necessary to reduce the risk of suggestibility. Finally, it is important to note that individuals with exposure to negative life events (e.g., the death of a parent or sibling, exposure to physical violence) may be more susceptible to suggestibility.

Conclusion

Given the importance of collecting accurate information, it is essential that mental health professionals acquaint themselves with the phenomenon of suggestibility. Unfortunately, many mental health providers lack the necessary awareness and training related to the detection and screening of suggestibility among clients.

Mental health professionals should seek to establish routine procedures to better identify clients who are at an increased risk of susceptibility to suggestibility before proceeding with the interviewing process. Such a procedure could include a validated suggestibility screening tool and a checklist of variables that research has found to increase risk of suggestibility among certain mental health treatment populations. We encourage mental health professionals to be aware of the various personality, social and cognitive factors that may influence some clients to be suggestible.

Suggestibility can have a negative impact on the various components of mental health treatment, including intake, screening, assessment, psychological testing, treatment planning, medication compliance, perceived understanding of treatment concepts, and discharge planning. For this reason, we urge mental health professionals to gain an increased awareness and understanding of this complex and multifaceted phenomenon.

One suggested step for moving the field forward is for mental health professionals to engage in self-study and continuing education via in-person and online training courses that focus on the evidence-based assessment and management of suggestibility. It is also important for mental health professionals interested in understanding suggestibility and its implications to review key research findings on at least a quarterly basis and to consult with recognized subject matter experts. Clinical interviews should be conducted through developmentally sensitive and suggestibility-informed approaches that consider the client’s psychiatric, neurocognitive, social and trauma history. By taking such steps, the potential negative impact of suggestibility can be minimized, thus paving the way for positive outcomes.

 

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Jerrod Brown is an assistant professor, program director and lead developer for the master’s degree in human services with an emphasis in forensic behavioral health for Concordia University in St. Paul, Minnesota. He has also been employed with Pathways Counseling Center for the past 15 years and is the founder and CEO of the American Institute for the Advancement of Forensic Studies. Contact him at jerrod01234brown@live.com.

Amanda Fenrich obtained her master’s degree in human services with an emphasis in forensic mental health from Concordia University. She is currently completing her doctoral degree in the advanced studies of human behavior from Capella University and is employed as a psychology associate for the Washington State Department of Corrections Sex Offender Treatment and Assessment Program.

Jeffrey Haun is employed as a forensic psychologist for the Minnesota Department of Human Services, where he conducts a variety of forensic evaluations and offers consultation, supervision and training in forensic psychology. He is an adjunct assistant professor in the Department of Psychiatry at the University of Minnesota and an adjunct instructor at Concordia University. He is board certified in forensic psychology.

Megan N. Carter is board certified in forensic psychology and has received the designation of fellow from the Association for the Treatment of Sexual Abusers. She has worked as a forensic evaluator at the Special Commitment Center, Washington state’s sexually violent predator facility, since 2008. She also maintains a small private practice focusing on forensic evaluations and child welfare issues.

 

Letters to the editor:ct@counseling.org

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