Monthly Archives: October 2019

Maldistribution: Mental health care in America

By Bethany Bray October 14, 2019

Access to mental health care varies greatly depending on where one lives in the United States. This variance is so great that Mental Health America (MHA) referred to the situation as a “maldistribution” of behavioral health providers in a recent report.

In Massachusetts, there is a mental health provider for every 180 residents, which marks the best ratio in the nation. On the other end of the spectrum is Alabama, which has the nation’s worst ratio at 1,100 residents for every one mental health provider. Texas, West Virginia, Georgia, Arizona, Tennessee, Mississippi and Iowa are the others states that have ratios of 700:1 or worse.

MHA, a Virginia-based nonprofit advocacy organization, compiles a report of mental health indicators each year from nationwide survey data, including information from the Substance Abuse and Mental Health Services Administration and the Centers for Disease Control and Prevention. In tabulating its ratios, MHA included counselors, psychiatrists, psychologists, licensed clinical social workers, marriage and family therapists, and nurses specializing in mental health care in its definition of mental health provider.

MHA’s report, The State of Mental Health in America, was released in September.

When weighing access to mental health care and insurance against prevalence of mental illness, substance abuse, suicidal ideation and other factors, MHA ranked Pennsylvania, New York, Vermont, Rhode Island and Maryland as the top five states (in that order) for mental health in its most recent report. Nevada was ranked last in MHA’s list, preceded by Oregon, Idaho, Utah and Wyoming.

The organization also recognized Rhode Island as rising from 27th to fourth in its overall rankings over the past six years. In contrast, Alaska has gone from 17th to 46th, Kansas from 18th to 42nd, and North Carolina from 16th to 35th during that same time period.

MHA tracks a number of other mental health indicators in its annual report, including statistics on youth and adults with substance use disorders, depression and suicide, as well as insurance coverage and rates of treatment and other data. MHA notes that rates of overall mental illness (defined as “having a diagnosable mental, behavioral or emotional disorder, other than a developmental or substance use disorder”) among American adults have remained relatively stagnant, increasing from 18.19% to 18.57% between 2012 and 2017. However, suicidal ideation among adults rose from 3.77% to 4.19% over those six years.

Of note is a more than 4% increase in prevalence of past-year major depressive episodes in youth ages 12 to 17 (an increase of 8.66% to 13.01% from 2012 to 2017).

“While ensuring that youth with mental health conditions have greater access to care is vitally important, the only way to address the rising prevalence of mental health conditions in youth is to address the upstream causes on a population level,” wrote MHA. “States must invest time and resources into researching and understanding the causes for this drastic worsening of mental health in youth ages 12-17 and generating meaningful and effective policies and programs to address mental health concerns before they reach the point of becoming a diagnosable mental health condition.”




Mental Health America’s The State of Mental Health in America 2020

When it comes to mental health, how does your state stack up?

View the full report and state rankings at

State-by-state ranking of adult mental health factors (page 16 of MHA’s report;




CT Online’s recap of MHA’s 2019 report: “America’s mental health disparities





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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.


Healing the healers: Counselors recovering from familial addiction

By Suzanne A. Whitehead October 8, 2019

It has been roughly 17 months since I wrote a piece for CT Online about my son’s struggle with addiction, and it is amazing how far he and our family have come since then. I felt compelled to write a follow-up, not just because he is my son, but also because in the past year, I have discovered that so many professional counselors’ and counselor educators’ family members suffer in silence.

Last year, I used an author pseudonym in my article. I did this for two reasons. First, out of respect for our son because he was still in residential treatment and I couldn’t ask him for permission at that time. Second, I wanted to preserve anonymity for both of us, afraid of the effects that discussing our story and revealing our identities might have. A lot has changed over the past year, however, and today, both my son and I are so much stronger for having the courage to speak out. We no longer hide behind the effects of this horrible disease. I have learned that by speaking up, the addiction no longer holds any power over our family. I hope in this article to offer some solace, support, understanding and love to those who are suffering in silence. We healers deserve to heal too, and my heart goes out to you all.

On Feb. 16, 2018, the police called us at 2:30 a.m. from the other side of the country — 2,600 miles away — to tell us that our beautiful, precious son had been found on the side of the road, passed out. We later learned that the heroin in my son’s possession had been laced with fentanyl–he had no idea. Heroin users never have any idea what they are truly getting. They assume it is the same product that they are used to, draw up the same “dosage,” and a few seconds after injection, it’s all over.  The police  told us  that they had found our son just in time. He was in the cab of his truck, his foot still balanced on the brakes, the heroin and needle next to his side, the tourniquet still strapped to his arm and accompanied by his faithful dog, who barked like crazy as the police pounded on the door. It is a miracle our son is still with us. It is even more miraculous that he now has over 14 months in recovery and in order to pursue what he calls his life’s work, is studying to become a substance abuse counselor.

I wish I could share with you the “miracle formula,”– a path that if everyone could just follow, they would be “OK.” If only … But, this disease of addiction doesn’t work that way. It has a mind of its own, and its victims must find the recovery that best works for them.

I attended the American Counseling Association Conference & Expo in New Orleans this past March and went to a session proctored by Geri Miller (author of Learning the Language of Addiction Counseling). She, along with two other presenters, Jennifer Kline and Ben Asma, tried to describe the nature of addiction to the audience: how tolerance builds up, how the brain becomes “hijacked” by the opioids, and the realities of withdrawal. They did an outstanding job  relaying what actually happens to a human being, and came as close as I’ve ever heard to describing the abject horror a person suffering from addiction must endure.

For those of us who have never experienced or witnessed a person in withdrawal (I am not a person in recovery, but am a licensed addiction counselor and professor who teaches addiction and counselor education), it is hard for people to truly understand its hell. My son had to go through it on the floor of a jail cell, writhing in agony. An addict no longer uses to get high – that ship has sailed a long, long time ago. They use only to avoid withdrawal.

When withdrawal starts, you begin to feel like you are becoming quite physically ill. Soon, you begin to sweat all over, then have uncontrollable bouts of freezing. Your skin begins to crawl; you start seeing double. Your gut aches as it never has. And then you begin to wretch violently.

Simultaneously, you lose control of your bowels, and getting to the toilet is no longer an option. The pain continues to grow as you lose the ability to stand up. Your stomach contorts and your head is in agony. You want to rip out your hair, your eyeballs, anything to make the wretched pain stop. You continue vomiting and soiling yourself, every few moments. There is no reprieve, no solace,  no hope. You are so “dope sick” now that you think you may die and loathe yourself so much that you no longer believe you are even worth saving. You know the one and only thing that will make this sheer hell on earth stop is if you can get some drugs in your system. You swear by all you have left within you that you will “quit tomorrow.” You must tell yourself this lie, because to realize that you can never quit on your own is too unbearable to fathom.

After several hours, or even a day or two of the above, you will do anything (just about) to get more drugs. You despise your very being, your reflection in any mirror, and the lies you constantly tell to the ones you love the most. Your shame and guilt seem insurmountable. Your spirituality is gone – it was one of the first things the drugs took away from you. There is no longer any hope, just the temporary relief of the heroin (or worse) coursing through your veins.

Each day, or several times per day, this hell is reenacted. Depending on tolerance, what you took, how often, withdrawals can start again in a matter of hours. When a person must detox without the benefit of using buprenorphine or a combination of buprenorphine and naloxone to slowly, medically and safely wean them off the substances, the hell can last for days or a week or more. Withdrawal from heroin use is rarely fatal; however, there are many serious side effects and people can die from dehydration. If they are not safely detoxed, their pulse often becomes thready, their PO2 oxygen levels drop, their blood pressure plummets and they may even slip into unconsciousness or start seizing. This is what happened to my son. The guards had to rush him back to the hospital after 36 hours to give him IV fluids. He was so gravely ill that he barely remembers this part. The hospital personnel patched him up and within a few hours, he went back to his jail cell. How we treat people who have unwittingly taken too much OxyContin and become victims of the pharmaceutical trade is unconscionable. It is now known that a person can become addicted to OxyContin within five days. And we treat these people, human beings, worse than wild animals.

To know my son survived this horror, alone, with nothing but Tylenol and something mild for nausea (which is vomited immediately), tears at the very fabric of my soul and violates all I hold sacred in this world. How he was treated was vile, but not uncommon. Many others who suffer from addiction and end up in jail receive the same treatment. They will face the legal system, as my son did, and pay for their crimes. But the horrendous lack of treatment, access to care or compassion, combined with the sheer inhumaneness they face, brings me to my knees. If people only knew…

There is no question that many people do horrid things when they become victims of addiction; the realities are painfully obvious. A cornerstone of recovery is the process of paying for  mistakes and learning how to make amends. Forgiveness from loved ones can come at a very heavy price, and forgiving oneself can ultimately become the hardest fought battle of all. Addiction is such a cruel, insidious disease, particularly because so many have such a difficult time in separating the behavior from the person. Understanding the horrible acts that some people commit, while also trying to see them as a person in severe emotional, physical and spiritual pain, is a significant and sometimes difficult juxtaposition. For those living with addiction, free will has been overtaken by the demands of withdrawal, and the self-deprecation that follows each usage is beyond daunting.

My intention in writing this piece is to help convey the utter destruction of opioid addiction and the ugly and purulent aspects of withdrawal. Once we truly understand this part of the disease, our entire paradigms change. It would be unconscionable to treat someone with cancer, heart disease, diabetes or emphysema this way. Yet we allow this to go on day after day after day. We lose over 116 dear souls to opioid overdoses in this country every day now, and the numbers continue to rise. We all share this plight because addiction can, and does, happen to anyone. Once we understand this, we can stop the blame and shame that has for centuries accompanied this disease and begin to proactively act.

Our son is still fighting this disease; he will for the rest of his life. So far, he is winning, but elements that test his recovery are always there. We continue to celebrate his victiories. The entire family went to his open Narcotics Anonymous meeting to watch him get his one-year keychain and cheered like crazy fools. The look of pride in his eyes said it all: it’s as if his life is now just beginning. He’s been volunteering 30 hours per week at a county outpatient and residential treatment center since September 2018 as he works on attaining his certification to treat those with substance use disorders. His compassion for those fallen is unparalleled; he “gets this.” His family couldn’t be prouder. What an incredible difference he is making in the lives of others every day. He is my hero, and I stand in awe of his contributions and bravery.

Narcotics Anonymous keytag (via

My other goal in writing this is to discuss the stigma that helping professionals face when our own loved ones confront addition. That reality persists, and when I feel brave enough to reach out, I have overwhelmingly found that so many others also suffer in silence. Because we are counselors, therapists, professors and educators, we—and others—believe that not only do we help heal others, we must somehow have all the answers and will always know and have the ability to intervene in cases of addiction — especially with our loved ones. The assumption (I surmise) goes that there is something gravely wrong with us when a loved one succumbs to addiction. Why didn’t we intervene and stop them? Unfortunately, it’s not a matter of becoming aware and then simply “stepping in.” Addiction is a bio-psycho-social-emotional disease, insidious in its approach, and deadly in its tracks. It is not exclusive and honors no perceived barriers — not religion, socio-economic class, ethnicity or any other categories or factors. Because secrecy, lying, excuses, stories, deception, and falsehoods are all part and parcel with this disease, even the most astute of us do not always recognize the signs of impending addiction. Before long, victims are well into their disease and, by necessity, the level of deception grows with each passing day. It’s called survival.

To blame the person who is addicted for using their survival instincts is antithetical to any help we can give them. So too is to blame the family members and loved ones, no matter their profession. The isolation I felt this past year was heart-wrenching, lonely, judgmental, sad, destructive, and purposeless. I have also found that this sense of isolation is shared by many of my comrades. I am mentally exhausted from hiding in the shadows, fearing recriminations and judgments from those who refuse to listen or understand.

As I test the waters and disclose our story, I am buoyed by the knowledge that there are so many of us who need a voice. We need to raise awareness that this disease knows no bounds and its victims are all of us. It’s time to stop letting addiction win. It’s time to stop being its unwitting counterparts. It’s time to treat the addicted person, the family, and the loved ones with humanity and compassion —- the same way we treat others with any type of potentially deadly disease. I’m determined to not let my professional colleagues suffer in silence. I feel your pain; I understand. Now, let’s get the word out.




Suzanne Whitehead is coordinator of the counselor education program at California State University, Stanislaus. Her main research interests include promoting increased access and humane treatment for those afflicted with substance use disorders; crisis and disaster counseling; and equity for DACA recipients, immigrants and refugees. Contact her at




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

Breaking the silence

By Charmayne Adams, Jillian Blueford, Nancy Thacker, Kertesha B. Riley, Jennifer Hightower and Marlon Johnson October 3, 2019

Painting racial slurs in public spaces. Welcoming hate-affiliated groups. Defunding safe spaces on campus for minority groups. Hanging Confederate flags in campus organization housing. These are just some of the examples of acts of hate that have taken place on college campuses and, more specifically, that we witnessed taking place on our own college campus. Even though the authors of this piece are now at different institutions, at the time this article was written, we were all graduate students at the University of Tennessee, Knoxville.

This past spring, hate struck our community once again. An image surfaced denoting racial intolerance and ignorance about the economic barriers that African American students face at predominantly white institutions. The text messages, phone calls, emails, and face-to-face conversations that followed the incident reminded us of a pain that is all too familiar — one that pulls us to try and take care of our community while simultaneously taking care of ourselves. Often, we take care of our community while neglecting to take care of ourselves. As professional counselors, we are able to conceptualize violence in a way that makes it feel less personal, but the constant reminder that this form of hate is personal makes it difficult to externalize.

This is not the first time that an act of hate motivated by race, ethnicity, gender, sexual orientation or other minoritized identity has happened on a college campus — and it certainly will not be the last. There was something about this incident, however, that pushed us to ask a question: What is our role as professional counselors and counselor educators in helping to support growth, healing and reflexivity when our learning communities experience hate acts targeted at individuals who hold minoritized identities? 

Campus-based hate crimes

There are many reporting organizations for hate crimes in the United States, but three of the largest are the FBI, the U.S. Department of Education, and the Anti-Defamation League (ADL). The FBI reported 280 hate crimes on college campuses in 2017, which was 23 more than in 2016 and 86 more than in 2015. Of those hate crimes, roughly 83% occurred against multiracial victims, African Americans, or individuals who identified as Jewish. Those hate crimes happened on a total of 110 college campuses, of which 60 had a graduate-level counseling program. That means that more than half of the college campuses had counselors-in-training and counselor educators embedded in their communities at the time of the hate crime.

Colleges and universities are not required to report their hate crimes to the FBI, but under the Clery Act, they are required to report them to the Department of Education. In 2017, 6,339 institutions (with 11,210 campuses) reported 1,143 individual hate crimes to the Department of Education. The FBI, the Department of Education and the ADL have all indicated an increase in the number of campus hate crimes. In addition, the ADL found that instances of white supremacist propaganda on college campuses increased by 77% in the 2017-2018 academic year as compared with the prior year.

These trends signal a shift in campus climate and psychological well-being at collegiate institutions — a shift that calls on the ethics and skills of our counseling community. We believe it is important to look at the ACA Code of Ethics and other counseling competencies to better understand how to develop intentional awareness and action to address the hate being witnessed on college campuses.

Our ethical responsibility to act 

Professional counselors are trained to promote wellness while attending to the developmental needs of our clients. Additionally, our responsibility to advocate with and on behalf of clients is embedded in our ethics code. In addition, the ACA Advocacy Competencies state that advocating on behalf of clients becomes especially important when clients hold a minoritized identity or an intersection of minoritized identities.

It is our responsibility as professional counselors to view these acts of hate on college campuses as attacks on our clients, students, community members, colleagues and friends who hold minoritized identities. We are trained to use skills such as empathic and active listening, reflection, and minimal encouragers to hold space for individuals to explore their feelings, behaviors and cognitions. We possess skills such as conflict resolution and crisis intervention that are especially important when considering the nature of this topic and the need for individuals of all perspectives to be heard. What better way to engage those skills than by standing against hate and creating safe spaces for individuals affected by these horrendous acts. We believe that all counselors — faculty, students, community professionals — can and must act.

Faculty responsibilities

To effectively address the manifestation of and respond to instances of hate and discrimination in our campus communities, counseling faculty must be proactive and reactive. This includes engaging in personal reflexivity, modeling tough conversations with colleagues, and intentionally structuring learning activities to increase student personal reflection. 

  • Personal reflexivity: This is an active and consistent reflective process in which faculty examine their internalized beliefs, values and biases. This might involve reflecting on your own cultural identity and any bias you may hold toward a particular group, or recording your thoughts, feelings and behaviors to bring greater awareness of your own responses when an act of hate happens on campus.
  • Modeling: Counseling faculty can readily engage in open and sensitive dialogue with their colleagues. As faculty model cultural norms by engaging in reflexivity and debriefing with one another, students can follow suit. Faculty could also engage in community dialogue if there are events for faculty and staff to process acts of hate on campus.
  • Intentional pedagogy: Counseling faculty can also be proactive by incorporating inclusivity throughout the curriculum. This includes facilitating learning environments in which students confront their biases and respectfully hold space for discomfort, or creating learning opportunities around diverse ways of thinking and being.

Counseling faculty can lead the way in being active responders to instances of hate and discrimination on campus. A strong first step is to respond and denounce acts of hate in a timely manner through the release of a collective statement from program faculty. Additionally, faculty can offer support to students at individual and group levels, both within and outside of the classroom. This may include having discussions with students on ways to respond and advocate as a unit for the greater campus community. It is important to remember that any collaborative campus effort should include other departments (e.g., student life, campus counseling centers) and helping disciplines, especially when offering debriefing or processing sessions with students, staff and faculty across campus.

Counseling students’ responsibilities

Students in counseling programs hold a similar but unique vantage point — navigating dual roles as members of the student body and as emerging professionals in the field.

As doctoral students, we felt the tug to dive in and start facilitating the healing work for our campus before we had processed what the hate act meant to us. We realized early on, however, that the first step we needed to take was to assess how the event had impacted our thoughts, feelings and beliefs about ourselves and our peers. It is important to have these conversations — both ongoing and in moments of crisis — within the counseling program. However, another way that we gained support as we processed these incidents involved tapping into campus affinity groups outside of the counseling department.

We also understood that we couldn’t engage in advocacy in a healthy manner if we weren’t taking care of ourselves. It was important for us to stay physically and psychologically healthy by:

  • Seeking personal counseling
  • Maintaining a nutritious diet
  • Getting enough sleep
  • Taking breaks from social media

These and other tips from the Immigration, Critical Race, and Cultural Equity Lab, founded and co-directed by Nayeli Chávez-Dueñas and Hector Adames, helped us manage our own mental health as students while remaining engaged in both our program and greater campus community.

Ultimately, counseling students serve as a bridge to campus and can provide fresh insights into current cultural and societal dynamics. This means that we are equipped to both guide and participate in conversations around instances of hate on campus. At times, this charge may be as macro as serving on a university committee that focuses on bias on campus or as micro as sharing frustrations and concerns with classmates. The key is finding what works for you so that you can sustain your practice of advocacy while maintaining your academic progress.

Together, as faculty and students in counselor education programs, we can contribute to a shift in campus climate by advocating for inclusive dialogue and reflexivity among students, staff and faculty across the higher education community. This is a process that will be ongoing and adaptive as the campus community evolves. Remaining silent and absolving ourselves of responsibility runs counter to our professional value of advocacy.

Community professionals’ responsibilities

Although we have seen an uptick of hate crimes on college campuses, these events certainly are not limited to our academic communities. These crimes occur every day in our cities and towns and affect countless individuals, including students, family members, community leaders, business owners and first responders. Some of these incidents are quite public; others are less visible and demonstrative.

As professional counselors, we need to broaden our understanding of the emotional, mental and physical tolls that hate crimes have on others. Communities of individuals who have endured discrimination for decades carry deeply rooted pain and are distrustful of society, often believing that others cannot understand their experiences. Long term, our lack of connection to marginalized communities threatens to further separate individuals, creating an “us versus them” mentality. People no longer want to understand and walk in the shoes of others; people begin to retreat behind fear and ignorance. To combat this trend toward division and isolation, professional counselors can become a unique and supportive force to help individuals heal and learn.

For us to engage with marginalized communities that have been hurt by these hate crimes, we must first look inward and then move outside the walls of the counseling office. We have an ethical obligation to do no harm to our clients, but first we must recognize and identify our biases and assumptions and recognize that traditional counseling settings are often inaccessible to minoritized populations.

All human beings carry implicit biases that direct how they engage with others — and particularly with individuals of different cultural identities. Professional counselors are not exempt from this natural human tendency, but settling for this often automatic response will create barriers for those needing services. If we do not challenge our own misconceptions, we will struggle to build authentic relationships with our clients and lose the meaningful connection needed to make change.

After reflecting on the preconceived notions that we carry into the counseling relationship, we must humbly and intentionally seek to join with communities to offer services in spaces that minoritized populations utilize. These spaces could include religious organizations, schools, community gardens, recreation centers and community centers. Do not let the burden of seeking services rest on the shoulders of the wounded. Go out and offer your skill set with humility, patience and genuine compassion to the communities affected by these acts of hate.

After we have engaged in the hard work of self-reflection and moving outside of the traditional counseling office, then we are better equipped to support clients from marginalized communities and to begin understanding their experiences. Supporting clients means seeking to understand rather than respond. Even if we hold minoritized identities ourselves, we have to continually strive to see how our clients are experiencing acts of hate and not speak for them but rather alongside them.

By educating ourselves on events happening in our communities, states and nation, we can gain insight into what is happening in the world of our clients. Although it is painful to see the hate occurring all around, we owe it to ourselves and to our clients to be proactive about educating ourselves, learning both within and outside of the counseling session. It is important to remember that the burden of enlightening the majority should never rest on the shoulders of the wounded minority. We must take responsibility for our blind spots as professional counselors and actively seek information that will better prepare us to support clients who hold identities that have been subject to power, privilege and oppression.

Education can lead to empathy and provide motivation to advocate and act. As professional counselors, we have certain privileges available to us, including access to administrators, law enforcement personnel, legislators and community leaders. We can also share our clients’ experiences with others. It is one thing to support our clients within the counseling session and another thing to recognize injustice and take action. Becoming involved with the community means:

  • Attending town hall meetings
  • Volunteering with community organizations
  • Writing letters to legislators
  • Voting
  • Holding office space for leaders to meet and have discussions
  • Not remaining behind the safety net of our counseling environment

We are advocates, and no act of advocacy is too small. What is small is expecting others to step in even though we possess the talents and resources to play a part in bringing about systemic change.

What we need from fellow counseling professionals

As individuals who hold minoritized identities, we need the support, action and advocacy of our community, faculty members and students. We do not have the privilege of feigning ignorance in the face of hate crimes, hate speech, discrimination or microaggressions because these actions are targeted at us. We must stay alert and assess each of these acts in an effort to ensure that we keep ourselves safe. We ask that you join our efforts to make our campuses and communities safer for individuals who hold minoritized identities.

The following is a list of action items that we see as important to combating these incidents and increasing a sense of safety for those with minoritized identities.

1) Examine your biases and prejudices. Our beliefs and values greatly influence our work with clients and students. As professional counselors and counselor educators, we are tasked with examining our biases and prejudices. Similarly, the ACA Code of Ethics requires that we attend to the welfare of students in our training programs, with a particular focus on the needs of students who hold minoritized identities. In examining our biases and prejudices, we communicate that we value our clients and students enough to do our own work, even when it is difficult.

2) Educate yourself. As we begin to uncover the biases and prejudices that we hold, it is our responsibility to seek education and accountability to further combat these harmful beliefs. Too often, the responsibility of educating and holding others accountable falls to minoritized students, further burdening them by making them speak for an entire group of people and tasking them with correcting long-held beliefs. While we (minoritized individuals) want to see this process take place, the responsibility should not fall solely to us. We need allies who are committed to staying educated and who resist shifting that heavy burden onto us, especially when our communities are hurting.

3) Be willing to make mistakes. We do not expect you to be perfect. In fact, we are still learning and growing ourselves and recognize that there will be times when mistakes are made. When those times happen, we ask that you remain open to hearing our perspective and choose to put down your defenses, seeing mistakes as opportunities to grow. Pause when you notice yourself becoming defensive or offering an explanation; simply stating that you are sorry is far more comforting to us than hearing any reason why the behavior was justifiable.

4) Seek to understand our experiences. It is inherent in the counseling profession to relentlessly seek to understand the experiences and perspectives of our clients while providing them empathy. Similarly, we can use these skills to better understand the experiences and perspectives of minoritized students. In doing so, we show these students that we are invested in them and that they matter. By providing this space, we allow students to process their experiences, and we learn more about what needs are not being met and how we can advocate with and for minoritized students.

5) Advocate. Advocacy is a core piece of our professional identity as counselors and counselor educations. Our advocacy efforts apply not only to our clients but also to students in counseling programs, and particularly to those who hold minoritized identities. We challenge you to advocate with us and for us when needed, recognizing that there are times when your position of power may allow you greater access and more authority. We need you to challenge your colleagues to join in this process as a way of uniting our profession to help support vulnerable populations. Please keep in mind that it is important to first understand the experiences and needs of those for whom you are advocating. Be sure to check in throughout the process. Without these check-ins, your advocacy efforts can feel disempowering to the population for which you are advocating.


This is a call to all counseling professionals working on and around college campuses: Be attentive, alert and active when incidents of hate occur. We are not only ethically mandated to step up, but we are well trained to do so. Our skills allow us to confront hate and discrimination with empathic communication and conviction for social justice. These unique qualities complement the needs of our campus communities in the aftermath of these acts of hate.

When we lean in together and speak with a unified voice for equity and justice, we embody our professional values of advocacy and holistic wellness. This is the time to act because our silence speaks volumes.




Charmayne Adams is an assistant professor of clinical mental health counseling at the University of Nebraska at Omaha with research interests in crisis, trauma, and counselor education pedagogy. Contact her at

Jillian Blueford is a clinical assistant professor for the school counseling program at the University of Denver.

Nancy Thacker is an assistant professor of counseling and counselor education at Auburn University.

Kertesha B. Riley is a third-year doctoral student in counselor education at the University of Tennessee, Knoxville, with research interests in graduate student mental health and STEM career development.

Jennifer Hightower is a second-year doctoral student in counselor education at the University of Tennessee, Knoxville, with research interests in suicidality and multicultural issues.

Marlon Johnson is an instructor at Seminary of the Southwest in Austin, Texas, with research interests in diversity recruitment and issues of burnout and persistence for underrepresented counselor trainees.


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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.

Counseling termination and new beginnings

By Victoria Kress and Marissa Marie October 2, 2019

When preparing for a symphony, a conductor will often tell the musicians that the last note is as important as the first; after all, the last note is what the listeners will take with them. For that reason, the final note of a symphony requires just as much artistry, thought and attention as the first note.

Much like the final note of a symphony, counseling termination requires a great deal of creativity and attention to detail. Although termination is an often neglected concept in the counseling literature, it is supremely important.

Termination is the term most commonly used to describe the process of finalizing or ending a counseling experience. Yet that word conjures up images of abrupt endings or even death, so we wish that a better phrase could be identified to describe counseling endings and transitions. Perhaps the words finale or commencement, or even the euphemism new beginnings, would better capture the termination process.

Many if not most of our clients have experienced traumatic or adverse life experiences. Thus, the termination process can be particularly triggering and take on an even more significant meaning for these populations. Because of its importance, we believe that the termination process merits a closer look.

Ethics and termination

Ethically, it is a counselor’s duty to prepare clients for the counseling termination process and to terminate services when clients are no longer benefiting from counseling. Therefore, counselors ought to be thinking about termination, even at a first session.

When the time comes to end the therapeutic relationship, it is natural for there to be feelings of grief and loss and even an adjustment period. Some clients may struggle to negotiate healthy boundaries and the termination of relationships. Furthermore, clients who have experienced abuse or trauma may be especially sensitive to relationship transitions. 

Ending a therapeutic relationship requires a great deal of thought. If done ethically and competently, termination can help solidify counseling gains, empowering clients to integrate their experiences and bravely face their next chapter in life. Termination can also help model healthy boundaries and a natural and appropriate end to a relationship. Effective termination provides clients with an opportunity for continued personal growth, whereas ineffective termination can actually harm clients.

Preparing clients for termination

To best prepare clients for termination, it is essential that counselors proactively address termination. Ideally, termination should be introduced during the informed consent process. In fact, by openly discussing termination from the beginning of counseling, counselors may help galvanize client motivation because clients will see counseling as something temporary that can be used to help them reach a defined set of goals.

By weaving the idea of termination into informed consent, counselors can also encourage and elicit client feedback regarding the progress being made in counseling. Thus, clients will be liberated from the fear of “disappointing” their counselor by raising the idea of ending counseling once they feel they have received what they needed from the counseling experience. Remaining transparent about termination, from the initiation of counseling, can help clients invest in reaching their goals while concurrently empowering them to voice when they feel they are ready to end counseling.

Counselor adjustment to termination

Just as clients often experience a tangle of feelings around the end of a counseling relationship, counselors themselves can have emotional reactions to termination. As counselors, we invest much time, emotional and intellectual energy, and dedication to helping our clients. After all, the lifeblood of the counseling profession is based on building a warm connection with those we serve. As a byproduct of this relationship process, counselors do indeed develop emotions and thoughts regarding their clients. Consequently, when the counseling relationship ends, there is an adjustment period for counselors too.

Ideally, this adjustment period would include a space for self-supervision, with counselors objectively evaluating their performance and efficacy with the client. Counselors can identify potential growth areas and reflect on their professional strengths as part of this process.

Before engaging in such objective evaluation, however, counselors may need to sort through their residual feelings of loss. These feelings may be further complicated by countertransference. If, for instance, a counselor’s personal experience aligned with that of the client who recently terminated, the counselor’s emotional reaction may be intensified. If there is a positive prognosis for the client, the termination process may catalyze feelings in the counselor of fulfillment, competency and even confidence. If, however, the client terminates abruptly or has a less than favorable prognosis, the counselor may experience feelings of incompetence and disillusionment, especially if the counselor’s lived experiences mirror those of the client. In these instances, counselors must make processing their emotions around termination a priority.

Although it is imperative to cultivate self-awareness surrounding countertransference throughout the counseling relationship, monitoring countertransference at termination may be especially important. Counselors ought to be cognizant of their emotions and willing to process these emotions, whether positive or negative, at the end of a counseling relationship.

In summation, while clients often experience grief and a sense of loss at the conclusion of the counseling process, counselors may also have emotional reactions to the termination process. Counselors should monitor these reactions, discuss them in supervision, consult with peers, and seek personal counseling if necessary to ensure that even as they adjust to the loss of a therapeutic relationship with a client, the quality of the services they provide to their remaining clients remains top-notch. Being aware that termination is a two-way street that affects the counselor-client dyad allows counselors to more effectively understand, and thus cope with, the emotions and thoughts that ending a therapeutic relationship may stir up.

Client ambivalence around termination

Even when counselors introduce the discussion of termination in the initial stages of the counseling relationship, it is natural for many clients to experience some anxiety and disillusionment with the idea. After all, the counseling relationship may be one of the only times, if not the only time, in their lives when they have experienced safety, trust, compassion and care. Given that these virtues are basic human needs, it makes sense that clients may be reluctant to end the counseling relationship.

Some clients may manifest this reluctance by continually raising “new” issues or concerns anytime the possibility of termination is mentioned. Clients may even return to the behaviors that led them to counseling initially. For example, a client who self-injures and works toward abstinence over the course of counseling may engage in self-injury again as the idea of termination nears. Rather than viewing this as a counseling failure, counselors should remember that, like counseling itself, termination is not linear.

At its core, termination involves the ending of a relationship, likely resulting in feelings of grief and loss. Thus, space should be made for clients to experience, rather than avoid, those feelings that come with the natural ending of a relationship. Encouraging clients to utilize the coping and emotional regulation skills they have gained over the course of counseling can assist in managing the emotions surrounding termination. This action also helps to reinforce the learning that occurred throughout the counseling process. Walking alongside clients as they grieve the loss of the counseling relationship allows them to experience the conclusion of a relationship in a nurturing and empathetic environment and helps them develop so that they can better manage future losses and transitions.

Counselors should continually assess for termination readiness when working with clients. One way to do this is to ask clients questions such as, “Do you think you are benefiting from counseling?” and “How will you know when our time here together is coming to an end?” Questions such as these set an expectation that counseling will end and serve to empower clients to help determine when it will conclude. By trusting clients and actively listening to their experiences and sense of how they are (or are not) benefiting from counseling, counselors help clients prepare for the termination process.

The termination process

When it comes to the actual process of termination, counselors can take many different approaches with clients. The interests and developmental level of clients and the content of counseling should all be considered when planning termination activities. Termination is often an ideal time to incorporate active, engaging and creative interventions that encourage clients to engage in active learning and reflection upon the counseling process as a whole.

Often, as termination nears, client engagement and enthusiasm in counseling diminish. By using active and creative termination interventions, counselors can inject new enthusiasm into the last several counseling sessions. Clients tend to more readily remember counseling interventions in which they are interactively involved.

Regardless of the specific intervention used, termination is an ideal time to incorporate an optimistic, empowering and future-oriented approach. Counselors can compassionately empathize with clients who are reluctant to terminate while concurrently encouraging them to see the end of counseling as a new adventure in which they can apply the skills they have learned throughout counseling. Assuming such a tone as a counselor assists clients in developing a future-focused orientation. This may help propel them through the natural grieving process that often accompanies the ending of a counseling relationship.

Creative termination activities 

A variety of creative termination techniques can be used with clients. Ideally, the counselor can dedicate several sessions to fully processing and exploring the termination process. A few examples of creative termination activities follow.

One-way trip for trauma: This activity can be used with clients who have worked on trauma issues or those who have worked to let go of something while in counseling. Clients can take the materials that they have accumulated throughout the counseling process that are associated with their trauma narratives — writings, journals, worksheets, illustrations, etc. — and either rip them up, color over them, or simply fold them neatly.

After the materials are collected, counselors should provide clients with a small box or container (these are easily obtained from everyday recycled products or by purchasing them in bulk on the internet). Next, clients can be given a variety of tape. Clients then
place their trauma narrative materials into the container, tape the container shut, and decorate the container as they see fit. At this point, counselors can process with clients how their traumatic past need not dictate their future. Clients can then discuss how leaving the counseling relationship symbolizes their having processed and worked through their trauma.

This intervention can also be paired with a “new beginning” celebration to signify the start of a new chapter in clients’ lives. Although shifting the language from “termination” to “new beginning” may seem like nothing more than a euphemism, the language is immensely important. Helping
clients who have a history of trauma understand that they do indeed have a future, despite the pain and hopelessness they have endured in the past, is a powerful intervention.

Sticker chart/memory book: Younger clients may struggle to fully grasp the concept of termination or to engage in metacognitive reflection on the counseling process as a whole. Thus, with these clients, more developmentally appropriate and artistic interventions are often indicated. For instance, a sticker or picture chart could be maintained throughout the counseling process, with clients placing a sticker on the chart each time they come to counseling. Clients can even draw pictures, along with using the stickers, to illustrate a “story” of their time in counseling. As termination approaches, clients can further illustrate their chart, review what they have learned so far, and place more stickers on the chart signifying their achievements in counseling.

Another effective approach is working together with younger clients to create a memory book with pictures, words, stickers and decorations that will help them remember their time in counseling in a more concrete manner. Both of these interventions allow child clients to take a tangible item with them as they end the counseling process.

Aloha lei (hello-goodbye) activity: Counselors can explain to clients that the word aloha means both hello and goodbye. Counselors can then discuss with clients that every end is the start of a new beginning, as is the case with the end of counseling.

For the activity, paper flowers can be cut out (clients can select the color of the materials to enhance autonomy). Clients can write effective coping skills, memorable counseling experiences, or other notable takeaways on the flowers. Next, punch a hole in each flower and thread them along the string. Family members or caregivers can also be involved in the process (with client consent), adding their own flowers to the lei. The lei can then be given to the client as a parting gift. This intervention involves creativity and metaphor in a way that summarizes the counseling experience while actively involving the client.

Building blocks: This activity can be tailored to clients of any age. During the final session, counselors can bring a number of building blocks, Legos, Jenga blocks, or other toy blocks to session. Clients can then construct a tower or creation of their choosing. Each block in the creation can represent a powerful moment in counseling, a coping skill clients now possess, or another skill clients have learned during counseling.

As the height of the tower increases, clients may become anxious, especially as the tower begins to lean. If the tower ultimately falls, the counselor can explain that, given the clients’ fundamental skills — the skills they assigned to each block — the tower can be rebuilt. This intervention helps clients understand that even if they experience the inevitable “falls” of life, they possess the fundamental “building block” skills to rebuild. This intervention is a tactile and empowering activity for the end of counseling.

Goodbye letter: There are many variations of a goodbye letter that can be used as the counseling process comes to a close. Counselors can provide a letter template with certain blanks to be filled in, or they can simply provide a blank piece of paper on which clients can write their own letter. Adding prompts or sentence stems for clients to complete can add a degree of structure to the letter.

There is flexibility in terms of the letter’s point of view. Goodbye letters can be written from client to counselor, from counselor to client, or even from the perspective of the process of counseling itself being personified. Possible writing prompts include “One thing I remember from counseling is …” or “The most memorable moment of counseling was …” Although counselor creativity can yield limitless possible prompts, it is important that the goodbye letter be narrowed to focus on the most relevant moments of the counseling process. It is also important to keep the activity strengths-based (as is the case with any termination activity).

Survivor tree: Survivor trees can serve as a creative intervention to foster and celebrate resilience in the final stage of the counseling relationship. They can be either simple or complex, depending on the clients’ developmental abilities. Survivor trees may be drawn out to explore clients’ areas of growth (the branches), clients’ future hopes and aspirations (leaves and buds), coping skills that clients have learned in order to stay grounded (the trunk and roots), and even what struggles clients have worked through in counseling (dead leaves beneath the tree).

As the tree grows and expands on the paper, the counselor can weave in the idea that trees survive multiple seasons every year. Some seasons leave barren branches, whereas other seasons are rife with leaves and buds. Nevertheless, the tree survives and continues to bloom, even after a cold or barren season. Clients can then reflect how their resilience has allowed them to overcome previous barren seasons. They might also reflect on how the skills they learned in counseling can help engender resilience during future difficult seasons of life. Taking the example of the tree eventually blooming despite the adversity of winter, clients can explore how they can go forth in life and bloom beautifully, no matter the adversities they face.

Making a case for counseling: With this activity, clients are invited to create a “case” and fill it with various objects to help them summarize and conceptualize their experience in counseling. Depending on the client’s interests, the case can take on a variety of forms (e.g., a purse, an athletic shoebox, a favorite cereal box). Client autonomy can be reinforced by allowing clients creative license in decorating and designing their cases.

Clients can be encouraged to include various objects in the box that they find important and valuable to the counseling process (e.g., a grounding stone, a worksheet with coping skills, a journal). Furthermore, clients can create decorative scraps of paper to add to the box. These papers can include notable moments in counseling, emotions surrounding the counseling process, skills learned, or other tools with which the client can face the future trials and travails of life outside of the counseling relationship. If family members or significant others are involved in the counseling process, they can also add items to the client’s case (if the client agrees to their participation). This intervention is relatively open to interpretation and can include myriad creative avenues to help clients gain closure.

New beginnings

Regardless of the specific intervention used, termination is a vital part of the counseling process. During termination, counselors should convey a great deal of warmth and compassion to clients, while simultaneously aiming to empower them and promote their self-worth.

To reiterate, it is important to understand that semantics matter. The word termination conjures up brutal images of loss. In truth, the end of counseling is really the start of a new beginning; it is as if one chapter is closing and counselors are handing the pen off to clients to write their own next chapters. In so doing, counselors play their role in helping to ensure that the next chapter will be a good one.

The end of counseling, just like the end of a symphony, is not simply the end. Rather, it is a resounding note that acts as a gateway to new beginnings.




Victoria Kress is a professor at Youngstown State University and a licensed professional clinical counselor supervisor, a national certified counselor, and a certified clinical mental health counselor. She has published a number of journal articles on counseling termination and further addresses the topic in her textbooks, Counseling Children and Adolescents and Treating Those With Mental Disorders. Contact her at

Marissa Marie is a licensed professional counselor working at Youth Intensive Services in Youngstown, Ohio. She uses trauma counseling with those who have been involved in the sex trafficking industry. Contact her at


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From the President: Calling all volunteers

Heather Trepal October 1, 2019

Heather Trepal, the 68th president of the American Counseling Association

The vision of the American Counseling Association is that “Every person has access to quality professional counseling to thrive.” Our organization’s mission is to “Promote the professional development of counselors, advocate for the profession, and ensure ethical, culturally inclusive practices that protect those using counseling services.” You might be interested to learn about some of the ways that we are working on carrying these ideas forward.

In late August, ACA CEO Rich Yep, ACA Chief Knowledge and Learning Officer Lynn Linde and I attended the United Nations (U.N.) Civil Society Conference in Salt Lake City. This year’s conference focus was on building inclusive and sustainable cities and communities. We were in attendance as delegates because ACA has received official nongovernmental organization status from the U.N. I was inspired to meet a number of high school and college students invested in volunteer and advocacy efforts. These students were particularly interested in volunteering their time to engage in advocacy around the issues of climate change and developing inclusive communities.

Delegates from across the globe were also in attendance to advocate for components of safe, inclusive and sustainable communities. The goal was to share knowledge and contribute to an outcome statement to affirm various elements of inclusive communities that support the U.N.’s 2030 Agenda for Sustainable Development. ACA participated in the conference with an eye toward advocating for the inclusion of mental and behavioral health within that plan. If you would like to read more about the conference or the outcome statement, see

ACA also continues to partner with counseling and stakeholder organizations here in the United States and across the globe. In late September, we partnered with our peers in the Australian Counselling Association and the Asia Pacific Rim Confederation of Counsellors to co-sponsor the sixth Asia Pacific Rim Confederation of Counsellors Conference in Brisbane, Australia. This month, ACA is co-sponsoring a conference with the British Association for Counselling and Psychotherapy and the Irish Association for Counselling and Psychotherapy called Let the Voices Be Heard! An International Conversation on Counselling, Psychotherapy and Social Justice, in Belfast, Northern Ireland.

To carry out ACA’s mission and vision, we rely on an army of members who serve as volunteers and leaders. Our volunteer leaders are busy working on ACA’s 16 standing committees and five current task forces. The task forces are working on climate change, the state of counseling research (its impact on the profession and the public), new professional/early career counselor concerns, sexual violence practice support, and professional advocacy training. In addition, the Governing Council will be meeting later this month to take on the business of the association, including moving our strategic plan forward by examining our priority goals for the coming year.

Given all that is happening, you may be wondering how you can invest in our organization and contribute. Easy! I would like to draw your attention to ACA’s 2020-2021 call for volunteers. This year, the call has expanded to ask for members interested in serving on committees and task forces, and in short-term or micro volunteering opportunities. President-elect Sue Pressman will be using these applications to make appointments for next year.

Volunteering can be as time-intensive or as time-limited as you desire. There are formal opportunities, such as serving on committees, but there are also other options, such as volunteering to write an ACA member blog. We need to know about your expertise, passions and interests related to the counseling profession and our organization. Our ACA members who serve as volunteers play an essential role in the organization. I hope that you will consider submitting your application to volunteer with ACA.