Monthly Archives: April 2020

Voice of Experience: It often comes down to grief

By Gregory K. Moffatt April 20, 2020

Somewhere along the way in our education as counselors, all of us studied great theoreticians such as Erikson, Piaget and Maslow. Their theories provide us with a general understanding of human behavior, and with that information we can develop clinical interventions. In my undergraduate days, I didn’t fully appreciate theory as much as I should have, but the further I traveled into my career as a counselor, the more I realized the importance of theory and how to use it.

But it isn’t just theory that is interesting to me. The insight behind the development of these theories is equally significant. How did these men and women come up with their theories to begin with? Have you ever looked at an invention and thought, “Wow, why didn’t someone think of that sooner?”

It is these potential blind spots that I have always tried to identify throughout the decades of my career. What am I failing to see? What might someone come up with in the future that would leave us wondering, “How did we miss that?”

And that is what brings me to the topic of grief. You’ve probably heard that “depression is really suppressed anger” or something very similar. We know there are often different emotions underlying the ones that we actually see in our clients. I’m convinced that grief is one of those underlying emotions in many cases.

When Elisabeth Kübler-Ross wrote her seminal work On Death and Dying in 1969, she was looking at grief only in the context of personal loss due to death. But later in life, she expanded her view to include other experiences of grief. Infertility, job loss, loss of health, and the death of a pet are among a host of other losses that one might grieve.

I’ve begun to believe that some of the dysfunction we see clinically is actually grief. When I was a very young man, my uncle once said to me that he grew up to “become everything I always hated.” What a sad thing to say. I didn’t realize it then, but I realize now that he was expressing grief to me — the loss of his dreams. He had hoped for one thing but achieved something quite different.

Addictions, affairs, anger and depression — to name a few things — may really be the client’s attempt to manage grief. A client struggling with fidelity in his marriage finally achieved an epiphany in therapy with me when he realized that his unfaithful behaviors had almost nothing to do with sex. Through extramarital relationships, he was seeking a fantasy — the thing he always hoped his marriage would be. In a way, he was in the bargaining stage of Kübler-Ross’ theory. “If I could just redo some choices in life, I would find happiness in a relationship with someone …”

Instead of grieving the loss of what he thought his marriage should have been, he tried to bargain his way through it. These bargains were illusions and, consequently, none of his extramarital relationships satisfied him. Once he was able to grieve the loss of the marriage he had hoped for, he was able to adjust his expectations and achieve a healthier relationship with his wife.

This doesn’t mean that we must settle for unhappiness. On the contrary! With resolution of grief comes peace of mind. Borrowing from yet another theory, perhaps this is akin to Rogers’ idea of the ideal self and the perceived self. No one suggests we stop dreaming of a better self, but there will always be a gap between these two “selves.” It is in the resolution of that disparity where strength of ego develops. Grieving the loss of the ideal can lead to healthier behavior.

In a sense, Erikson said as much regarding the final stages of psychosocial development — generativity versus stagnation and integrity versus despair. These two stages are successful, at least in part, when one has achieved a sense of accomplishment.

If a person can look back on life and find satisfaction with its direction, it provides a sense of “I did good” and allows one to sleep well at night. There is no grieving. On the other hand, looking back and ruing decisions and the direction of one’s life leads one to feel stuck and hopeless. This is grief — the loss of one’s expectations.

I suppose what I’m trying to communicate is that if we can see how grief might be driving our clients’ dysfunctions, then what we should be treating is grief rather than just depression, addiction or other symptoms of grief. We cannot change loss. Facing it and finding ways to cope are the keys to resolution.

 

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Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

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Recently published: See Gregory K. Moffatt’s article in the April issue of Counseling Today: “The need for standardization in suicide risk assessment

 

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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.

The counselor’s role in community outreach and resiliency building

By Denise Takakjy April 15, 2020

Professional counselors do not practice in a vacuum. Counselors practice, regardless of the setting, in community with others. Counselors practice in neighborhoods, in schools, in mental health agencies, in inpatient mental health hospitals, in colleges, in homes, in homeless shelters, in assisted living homes, in prisons, and the list goes on. All of these areas of practice are in communities. Therefore, we must be aware as counselors of the issues that affect the communities where we practice.

Communities are often affected by traumatic events and experiences such as community violence, drug and sex trafficking, police shootings, crime, substance and alcohol abuse, and parental abuse and neglect toward children. As a licensed professional counselor, I work primarily with children and adolescents who have extensive trauma histories. I provide trauma therapy in the form of trauma-focused cognitive behavior therapy. I also work within my community to provide trauma education to organizations such as day care centers to help these educators understand trauma’s effects on young children. My goal is to provide more community outreach through education and training to enable communities to become more trauma informed and resilient.

In this article, I will discuss the pivotal role that professional counselors can play in developing resilient communities through outreach. Counselors possess the expertise, experience and training to help communities develop programs necessary for addressing and ending the adverse effects of events that have taken place within these communities.

Adverse childhood experiences

Adverse childhood experiences (ACEs) have been shown to have an impact on future health implications and violence victimization. These experiences can include:

  • Abuse
  • Neglect
  • Witnessing violence in the community
  • Witnessing domestic violence in the home
  • Having a caregiver or loved one experience a prolonged illness, mental health crisis or death
  • Having a loved one die by suicide
  • Being separated from biological parents
  • Being in the foster care system
  • Having a loved one engage in substance or alcohol abuse

Each of these experiences can lead a child to feel unsafe and to struggle with stability and attachment.

Early ACEs will have long-term impacts on children well into adulthood. ACEs have been linked to unsafe behaviors, chronic health problems, poor academic achievement, lower rates of graduation, more lost time at work, and early death. The original ACEs study was conducted by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente from 1995-1997 in Southern California. The conclusion of the study was that those who had experienced four or more ACEs were more likely to experience increased health risks for alcoholism, drug abuse, depression and suicide. These individuals were also more likely to experience poor physical health, have multiple sexual partners, contract sexually transmitted diseases, experience obesity, have limited physical activity, and engage in smoking. Among the physical problems noted among adults who had experienced four or more ACEs were ischemic heart disease, cancer, chronic lung disease, liver disease and skeletal fractures.

Another study, the Philadelphia Urban ACE Study, was conducted to determine how ACEs affected those in a large urban city with a socially and racially diverse population (the original ACEs study from the CDC and Kaiser Permanente involved mainly individuals who were white, middle class and highly educated). The Urban ACE Study found that 33% of adults in Philadelphia had experienced emotional abuse in childhood, while 35% had experienced physical abuse in childhood. Other findings included that 35% of adults in Philadelphia had grown up in homes with a family member who abused substances, whereas 24% had lived in homes with a family member who was mentally ill. About 13% of adults had childhood experiences of someone from their household being incarcerated.

These two studies demonstrate a need for a) early intervention trauma treatment and b) outreach to provide collaborative support to build more resilient communities. For communities to become resilient, there must be support for the well-being of children and their families. This is where professional counselors can become strong advocates for the clients they treat. Many of the children, adolescents, adults, families and couples that we treat are currently experiencing problems that may be related to ACEs. So, what can we do as counselors to build resiliency within our communities?

1) Understand the trauma response. Counselors should do what they can to become more trauma informed. This means understanding what trauma responses are and what these responses look like. In my own practice as a trauma-informed child and adolescent counselor, many children come to me with diagnoses of attention-deficit/hyperactive disorder, oppositional defiant disorder, depression, anxiety, conduct disorder, obsessive-compulsive disorder, developmental disorders, intermittent explosive disorder, and pervasive disorder. Many of these children have been seen by multiple mental health providers who have worked to extinguish the challenging behaviors that accompany these disorders. Parents are at their wits’ end because “nothing seems to work.”

What I often find is that no formal assessment of trauma symptoms has ever been performed to determine whether these children might be experiencing a trauma response. Understanding how trauma affects the brain can provide counselors with an awareness of where certain behaviors are originating. Traumatized children are not able to regulate emotions, tolerate distress or learn because the centers of the brain that control these functions have not developed appropriately. The body is in a constant state of stress, and the child is in the fight, flight or freeze state. So, the behaviors and emotional problems that we are seeing may actually be stress responses from trauma.

2) Screen for trauma symptoms. Trauma screening should be done on all clients whom counselors see. It should be a part of every intake. Not every client will screen for trauma symptoms, but when they do, counselors will have the information needed to begin trauma-focused therapy or to refer to other counselors who have that training.

Counselors can conduct outreach to their communities by providing trauma screening to organizations or by teaching those within organizations to screen for trauma. Trauma can be screened for in physicians’ and pediatricians’ offices, day care centers and schools. I conducted an in-service training in which I taught educators at a local day care how to recognize behaviors that might be a result of trauma and understand why these behaviors occur. The training was well received, and these educators are usually among the first to recognize when children are having behavioral or emotional difficulties. Once communities can conduct an initial screening, then an assessment for trauma symptoms can be made that will lead to recommendations for treatment.

3) Advocate for appropriate mental health services within schools and communities. Budget cuts in many organizations within the communities where counselors practice often target mental health services, resulting in the discontinuation of services. In my area of practice in Pennsylvania, when the educational budget needs to be trimmed, school counselors are usually cut. This leaves one or two counselors to serve a school with hundreds of students. Some schools do not have the benefit of having other mental health professionals in their buildings. There may be one or two school psychologists to serve a district of five to 10 schools. Thus, the ability to screen for trauma is nearly nonexistent due to the absence of personnel to conduct those screenings.

Professional counselors can reach out to collaborate with school districts in the areas where they practice. In my practice in both agencies and private practice, I enjoyed working with many school counselors who asked me to help support their students. I always reached out to coordinate with school counselors to plan how to best help my clients. This is very beneficial for clients because they then receive collaborative support within the school. Counselors may also have the opportunity to contract with schools to provide supportive mental health care to students.

4) Advocate to build more trauma-informed communities by reaching out to lawmakers. Counselors can reach out to legislators when issues of mental health come up. Counselors can advocate for more school counselors and for trauma-informed training of school personnel and personnel in other social services agencies, including children and youth agencies, foster care agencies and welfare services. Counselors can advocate for their clients by encouraging legislators to work within their districts to develop mental health programs that are more accessible. Many adults cannot afford mental health services. Counselors can be on the front lines advocating for affordable health care that includes mental health parity.

5) Support the integration of mental health care in pediatric medical offices and physicians’ offices and training for first responders. Counselors can reach out to pediatricians and medical providers to raise awareness of the need for trauma screenings. Some already conduct these screenings. Some may conduct these screenings but offer no referrals for help. Partnering with these medical services and working collaboratively with medical personnel will encourage greater screening of trauma among patients and allow medical personnel to provide their patients with referrals to mental health services. In addition, counselors can offer to provide trauma training to organizations that train medical workers. The more trauma training that medical professionals have, the more resilient the community is likely to become because referrals for mental health services will be made earlier.

One trend that is occurring is more first responders being trained to identify trauma symptoms. First responders are often the first to arrive when someone is in a mental health crisis. Unfortunately, the news is too often filled with stories about law enforcement personnel shooting and killing individuals who were having a mental health crisis. Teaching safer alternatives for first responders to engage with and de-escalate those in crisis is another area in which counselors can provide outreach to their communities. Creating more mental health crisis teams within communities can be effective in reducing the number of deaths that occur when individuals suffering from a mental health crisis meet untrained first responders.

6) Advocate for trauma-informed schools. Professional counselors can collaborate with schools to train all school staff on trauma-informed care. Helping school staff to recognize when a student might be exhibiting trauma responses will allow them to provide needed support until the student can be evaluated by the school counselor or a mental health professional.

Counselors can also collaborate with schools to develop anti-bullying programs and sexual assault awareness programs. Bullying and sexual assault cause trauma to many students and will result in emotional and behavioral problems in school. Traumatized students are unable to focus and learn and will tend to isolate themselves. Students may exhibit acting-out behaviors such as tantrums or oppositional behaviors. Some students may hold their trauma inside and exhibit depression and anxiety symptoms.

In my experience working with adolescents where anti-bullying and sexual assault awareness programs are already in place, I often hear reports that these programs are ineffective. I see this as an opportunity for professional counselors to develop evidence-based programs that are
truly effective.

Conclusion

Studies have demonstrated the long-term effects of ACEs, particularly in communities where poverty, substance abuse, alcoholism and violence are the norm. Counselors can provide outreach to their communities and advocate for their clients and communities to develop trauma-informed programs and early intervention.

The ACA Code of Ethics tells us that advocating for our clients is an important part of the work we do. My challenge to you, my colleagues, is to think about the many ways that you can advocate for your clients and your communities.

 

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Denise Takakjy is a licensed professional counselor, national certified counselor and licensed behavioral specialist working in private practice in Harleysville, Pennsylvania. She specializes in providing trauma-informed care to children and adolescents with extensive trauma histories. Contact her at dtakakjy@healingheartshealthyminds.com.

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

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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.

The need for standardization in suicide risk assessment

By Gregory K. Moffatt April 14, 2020

“I am afraid I might actually do it,” the 31-year-old woman told me. Abigail (not her real name) was referring to ending her own life. For years she had struggled with depression, and she teetered on the brink of suicide. Medication had helped her only minimally. Her ideation was unquestioned and her plan was clear.

These were frightening words to me, and for weeks I held my breath, fearing a phone call from her husband announcing that Abigail had completed suicide. A brief hospitalization had somewhat stabilized Abigail’s life, but she was worn out. Upon her release from the hospital, her husband and I worked together to form a safety plan in an attempt to ensure that he wouldn’t be left a widower and her two children left motherless.

I have seen many clients like Abigail over the span of my career as a licensed professional counselor. Managing clients who are suicidal is a common occurrence in therapy. Data are scarce regarding the percentage of suicidal clients a clinician in general practice might have. However, most of the numbers indicate that up to half of an average client caseload is on the worrisome side of the suicide risk continuum. That percentage is far greater, of course, among clinicians who work with specific populations or disorders that have been shown to have increased risk for suicide. Abigail fell into one of these high-risk categories. Yet as recently as 2006, a meta-analysis by Stefania Aegisdottir and colleagues published in The Counseling Psychologist basically indicated that clinicians aren’t very good at assessing risk. That is frightening.

Equally disturbing is research showing that about one-quarter of us will experience the loss of a client to suicide during our careers, but many (if not most) of us are poorly prepared to manage suicide risk. In a 2013 study by Cheryl Sawyer and colleagues of 34 master’s-level counseling students, 15% reported no confidence at all and 38% reported little confidence in their ability to assess for suicide risk, whereas only 3% reported feeling fully competent to manage suicide risk.

But the problem isn’t just with graduate counseling students. In spring 2017, I presented a workshop for my state professional counseling association’s annual conference. The workshop focused on assessing risk of harm to self or others. I asked the 85 or so participants if they regularly worked with clients who were suicidal. Every hand went up. I then asked if they felt that their training had adequately prepared them for assessing suicide risk. Only two people in the entire group indicated that they felt prepared.

This response is consistent with an article titled “Psychologists need more training in suicide risk assessment” that appeared in the April 2014 Monitor on Psychology. The article, which detailed a task force report and summit organized by the American Association of Suicidology (AAS), said in part, “After three years of study, the AAS task force … called for accrediting organizations, state licensing boards, and new state and federal legislation to require suicide-specific training for mental health professionals.” The article went on to say that “many psychology graduate students are trained only on suicide statistics and risk factors, not in clinical methods of conducting meaningful suicide risk assessments.”

Something is amiss. Not only does it appear that mental health professionals receive inadequate training in this area, but some researchers even question whether the little training we do get has any efficacy. Robert Cramer and colleagues, writing in 2013 about suicide risk assessment training for psychology doctoral programs, stated that “no existing training methods have been investigated specifically in traditional clinical or counseling psychology training settings and samples.”

Although the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders addresses suicide risks by diagnosis, it does not provide any risk assessment tools for clinicians. Given the picture I’ve painted, how can it be that in 2020, we do not have any clear standard — often referred to as best practices — for suicide risk assessment?

Looking back

To identify what blind spots the counseling profession might have, I try to imagine what people will say about our field 50 or 100 years from now. After all, it is easy to look at the past and recognize our errors and oversights. As developmental psychologist Jerome Kagan wrote in Three Seductive Ideas (2000), “If you had lived in Europe as the fifteenth century came to a close, you would have believed that witches cause disease … and that pursuit of sexual pleasure depletes a man’s vital energy and guarantees exclusion from heaven.”

These ideas sound ridiculous today. If you are younger than 30, the following facts from the more recent past will sound equally ridiculous to you:

  • If you were a mental health person in the 1930s, “moron” and “idiot” were formal classifications of what we now call developmental delay. In addition, you believed ice water baths and jumping on a person’s chest could cure schizophrenia.
  • If you were practicing in the 1950s, common treatments for depression included prefrontal lobectomies. Some physicians literally lined patients up and performed these barbaric procedures in 10-15 minutes each.
  • If you were practicing therapy in 1970, you believed that homosexuality was a mental illness. Just a few years ago, some people believed in and actually practiced praying homosexuality out of a person (one of the milder techniques used in so-called “conversion” therapy).
  • In the early 1980s, hardly anyone had heard of AIDS, stalking, Munchausen syndrome by proxy, or autism.
  • When I was in graduate school in the mid-1980s, none of my master’s or doctoral professors even mentioned what we now call “evidence-based” therapies. Cognitive behavior therapy was leading the way, but most of us described ourselves as “eclectic,” and after our supervision hours were satisfied, we all basically did whatever we thought worked.

The lack of exactitude in the mental health field doesn’t end there. When I was a regular lecturer at the FBI Academy in the 1990s, I began receiving calls from around the country about various applications of counseling to law enforcement. One call came from a sheriff’s department. Five officers had been involved in a shooting, and departmental procedure required a fitness-for-duty assessment. The sheriff was asking me to do the assessments, so I began researching this facet of risk assessment and discovered there was no standard whatsoever in the field regarding fitness for duty. It was simply a judgment call on the part of the clinician. Hard to believe, isn’t it?

Apparently, we have a lot to learn. I’m hoping that in the not-too-distant future, therapists will be saying, “Remember back when there was no standard for suicide risk assessment? Unbelievable!”

Risk assessment tools

It would be easy to confuse lack of a standard with lack of tools. We have lots of tools. Among the assessment tools commonly used are the Beck Scale for Suicide Ideation, the Reasons for Living Inventory, the Suicide Probability Scale, the Suicide Intent Scale  and the SAD PERSONS scale, to name just a few. However, there is very little, if any, data clearly demonstrating that one tool is better than another or that assessment tools have any efficacy at all.

One exception is the Beck Scale for Suicide Ideation, which is as well-researched and as validated as any instrument available. But there is still no assumption that clinicians use “evidence-based” assessments. Does that sound a little crazy to anyone but me?

In a 2016 article in the Journal of Psychopathology and Behavioral Assessment, Keith Harris, Owen Lello and Christopher Willcox identified a number of issues with the standard practice of suicide risk assessment, but again, there is no consensus in the field. The authors noted that “an American Association of Suicidology task force … and other experts have called for improved teaching guidelines on valid risk assessment. The findings of this and related studies bring to light weaknesses in current suicide risk assessment and conceptualization, and concerns that some clinical educators and practitioners may be unaware of the limitations of popular tests. There is a clear and present need for updating core competencies for accurate assessment and risk formulation.”

How do we know our assessments are effective?

I’ve never lost a client to suicide, and it would be tempting to suppose that this indicates my system of suicide risk assessment and intervention is effective. However, there are multiple factors unrelated to my competence that might lead to the same outcome. For instance, clients who come to counseling might simply be more motivated to live than those individuals who don’t come to counseling. In such cases, perhaps any adequate therapist would have been effective.

There may be other factors in my clinical work that are the cause of my fortunate success. In other words, perhaps I have been doing something else that works (maybe good rapport or social support), but I’m not aware that this is what is actually helping as opposed to my suicide assessment and intervention. And, of course, I could have been wrong in assuming risk at all. These potential false positives could mean that my clients didn’t kill themselves because they weren’t really suicidal to begin with. And these are just three possibilities.

This is why we need research and standardization. Standardization adheres to accepted research format. My students often start comments and questions with “I think …” or “I feel …” I never let that slide. I don’t care what we think or feel. What do we know? That is what research — evidence-based practice — helps us answer.

I understand that my words may be hard to hear. Before evidence-based therapies became the ethical standard, all of us in mental health were doing what we thought worked. Any challenge to our practice was met with a defensive posture, and I was among the clinicians taking that stance. We felt or believed (just like my students) that our methods worked because our clients appeared to get better. We were certain we were right, and maybe we were, but we had nothing concrete on which to base our assumptions. That seems obvious in hindsight, but the thought was new to us at the time.

Some of our clients might have seemed better but really weren’t. Their desire for improvement might have masked symptoms, and we also know that clients want to please us. They might easily have presented their cases in a brighter light than they should have. Other times, they might have been better temporarily but regressed after terminating therapy. We can easily misinterpret our positive feelings about our work as evidence that it is effective. Could we be making similar mistakes right now in risk assessment for suicide?

A perfect case in point is no-harm contracts. One of the things that clinicians seem to agree upon widely is that there are benefits to using no-harm contracts — also called safety contracts — with our clients who are suicidal. Yet years of attempts to validate the efficacy of no-harm contracts have turned up nothing. M. David Rudd, Michael Mandrusiak and Thomas Joiner Jr. noted in a 2006 article in the Journal of Clinical Psychology: In Session that “no-suicide contracts suffer from a broad range of conceptual, practical, and empirical problems. Most significantly, they have no empirical support for their effectiveness.” A 2005 article by Jeane Lee and Mary Lynne Bartlett reported the same thing. In other words, the one thing that almost all of us do has no data supporting its efficacy.

What we risk

When I’m working through clinical issues, I find it helpful to think of what I would say if I were sitting in front of the ethics committee of my licensing board or if I were being scrutinized in court by a hostile attorney. How hard would it be for an attorney to find 10 clinicians who would propose that I made the wrong decision? If all you can say is, “I thought this was a good idea,” then you have a very weak defense.

In such cases, we risk losing a lawsuit and perhaps having our licenses censured, suspended or revoked. The more important risk, however, is that we might fail our clients and they might lose their lives when we could have served them better.

A standard approach

I’m not the first person to notice this problem, of course. AAS, among other groups, regularly focuses on the development of reliable and valid processes for assessing suicide risk, but as of yet, the solutions are elusive. A number of research studies have attempted to address the issue. James Christopher Fowler summarized well in a 2012 article in Psychotherapy when he wrote, “We are not yet in possession of evidence-based diagnostic tests that can accurately predict suicide risk on an individual level without also creating an inordinate number of false-positive predictions.” This summary brings us right back to where we started.

Combing through the research over the years, I’ve narrowed what we know about risk into a three-factor risk model and five components of risk in my assessment process as a starting place for evaluating the efficacy of risk assessment. I’m not supposing that my work is original or that my system is better than another. I’m only proposing that what I present here is consistent with what we know and that it can serve as a starting point for collecting evidence and producing a standard of best practice.

Three-factor model: The three-factor model proposes that clients are at risk or protected from risk in three global arenas: presenting factors, personal factors and protective factors.

Presenting factors include diagnoses (depression, for example), loneliness, divorce, prior attempts, suicidal ideation and other situational factors that put clients at higher risk for suicide. 

Personal factors include pessimism, weak problem-solving skills and minimal coping skills that put clients at higher risk for suicide. Included here are actuarial data. Some populations, such as female African Americans, have been shown to have very low risk for suicide, whereas others are statistically very high (e.g., Native Americans, male Caucasian teens, the elderly).

Finally, protective factors counterbalance presenting and personal factors. This would include healthy relationships, strong social support networks and religious commitment.

Moffatt’s HM4: The model for assessing risk that I use addresses all three factors. My HM4 model has five components of examination — hopefulness, method, means, motivation and mitigating circumstances.

The research is clear. People without hope are at high risk. Sometimes this is called “future orientation.” Regardless, the question is, “What does my client have to look forward to tomorrow, next week or next year?” If the answer is “nothing,” then I’m worried.

Method refers to one’s plan. The more specific and clear the method, the more I’m concerned. “I sometimes think the world would be better if I just didn’t wake up” is a vague plan. “I have been collecting my mother’s medications a little at a time. I have them hidden in my room, and I plan to take them all at once when everyone leaves for work and school” is a very precise plan.

Means has to do with the tools to be used and the ability to carry out one’s method of dying by suicide. One of the children in my practice once said he wanted to kill himself. His method was to invent a robot that would kill him in his sleep. His method was clear, but the means of executing that plan were completely unrealistic. Even if he could have invented such a robot, the likelihood that he would be able to carry out this plan without attracting his parents’ attention was minimal. On the other hand, teens and adults often have much more realistic means and, because of freedom of movement and access to weapons, drugs and other resources, are much more likely to succeed in a suicide attempt.

Motivation refers to the level of desire to follow through and complete suicide. Fortunately for us as counselors, most of our clients don’t want to die. Their motivation is low even though their emotional pain is high. This is why suicide hotlines work. People are so highly motivated to find a solution (having low motivation to complete the act of suicide) that they will call a complete stranger to seek help. 

Finally, mitigating circumstances are issues that are so weighty that they override the other areas of assessment. Mitigating circumstances can either increase or decrease risk for suicide. My concern for a high-risk client might be overshadowed by the person’s religious beliefs about suicide or by their desire to avoid hurting their children, spouse or parents. “I couldn’t do that to my children” is something that I’ve heard many times from high-risk clients. “My uncle committed suicide, and it devastated my father’s family” is another. Readers might recognize that hope is a mitigating factor, but it is such an important one that it has its own place in my model.

Assessment of Abigail

Abigail’s risk was clear. She was in a high-risk gender, age and diagnostic demographic; she had been contemplating suicide for a very long time; and she had a clear plan. She had been in emotional pain for many years and, most frightening to me, she had little hope of anything ever getting better. Her efforts to improve and the efforts of others to help her, in her estimation, had been futile. She had purchased a poison specifically to have it available if she decided to kill herself (method), and it was presently in her possession (means). I am positive she was motivated to follow through because getting the poison was not easy. She was willing to work hard to prepare for her own death, so I could have little confidence that she wouldn’t follow through. 

Among several mitigating factors in Abigail’s case was that she loved her children and didn’t want to abandon them. Also, she was certain that her religion did not permit suicide, and she feared “an eternity in hell” if she killed herself. Also working in her favor was that she possessed at least enough hope to keep our appointments. She was willing to at least try to let me help her even though she was unsure it was getting her anywhere. She came to therapy several times a week and was willing to trust that life might improve. Finally, she pursued medication for her depression and continued to engage in the business of life. 

Abigail is still alive today, and even though she struggles at times, she reports that she is doing better, that her depression has been managed, and that (now a grandmother) she is finding some happiness in life with her grandchildren.

Conclusions

If I sound overly critical of our profession, it is unintentional. It isn’t that I think we don’t know anything about suicide and risk assessment. On the contrary, there are mounds of data on statistics, risk factors, assessing and so forth. I attended a fantastic education session on suicide risk assessment at the American Counseling Association’s 2018 conference. The session was packed out, the presenters were fabulous, and the information provided was very helpful, but the very nature of the workshop demonstrated that we lack clear standards. Nearly all of us seem to be asking the same question: What do we do?

Without a standard for suicide risk assessment, clinicians face two very serious risks. The first and most important is that failure to standardize may leave our clients at risk for self-harm. Just because we have individualized systems that we believe are working doesn’t mean that they are working. The second issue is self-protection in the event of a lawsuit or a complaint against us with our licensing boards. The existence of best practice standards would allow us to defend ourselves.

Although there is no standard assessment for suicide risk currently, it isn’t beyond our grasp. In the 1990s, the medical community began looking at the use of a research-based protocol in emergency room heart treatment. Malcolm Gladwell described this process in his 2007 book Blink. Physicians resented the simple three-question protocol and were incredulous that anyone would suggest that such a simple tool could offer better triage than their professional experience did. Yet data proved that the protocol was superior in saving lives. The protocol is now standard in the medical field. The same process can be achieved in our field as well, but it depends on our profession’s willingness to study it and to accept the results.

 

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Gregory K. Moffatt is a veteran licensed professional counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University in Georgia. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. He also writes the monthly Voice of Experience column for CT Online. Contact him at Greg.Moffatt@point.edu.

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

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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.

How to help domestic violence clients during shelter-in-place situations

By Federico Carmona April 13, 2020

It’s heartbreaking to read the variety of articles circulating about vulnerable people trapped at home with their abusers because of shelter-in-place mandates during the COVID-19 pandemic.

Unfortunately, experience reminds us of a concerning reality that is typical of these uncertain times: Adverse labor market conditions are positively related to domestic violence. Research conducted after the Great Depression of the 1930s, the farm crisis of the 1980s, and the Great Recession of 2008 found that economic crises have significant negative effects on the quality of intimate relationships and parenting in working families. Marital conflict, abuse (particularly violent controlling behavior), and a decline in parenting quality are among the harmful effects in families of a macroeconomic downturn.

In my role as a trauma therapist, I have seen dozens of domestic violence clients during clinical intakes and in counseling. I have also read a multitude of articles on the subject about studies and reports from different parts of the world. Shelter-in-place mandates aren’t a good thing for women and children who are the targets of abuse. The anticipatory anxiety and uncertainty of these times can cause negative emotions to churn, leading to behaviors that increase the already-concerning number of domestic violence and child abuse cases. There is no “how-to” manual to deal with the current situation, of course, but the safety of this vulnerable population demands us to do our best.

How can the counseling community help domestic violence clients who are trapped at home with their abusers? I offer a few suggestions:

Reach out between appointments/sessions. One of the critical signs of abuse is the isolation of victims of domestic violence from their networks of love and support. An occasional check-in from us can empower these clients to tell us more about their situations and perhaps even dissuade their abusers from further violence as we keep checking in.

Listen, just listen. People experiencing domestic violence need an empathic ear — someone who will allow them to vent their repressed emotions and feelings without judgment. We are not to offer advice, only listen and empathize. It’s just time to build trust.

Validate clients’ feelings, emotions and beliefs even when they don’t make sense. The best way to build trust with clients experiencing domestic violence is by being present with them. We’re present with them through our vicarious empathy, active listening and compassionate validation. Our empathy is vicarious because it takes an emotional toll to connect with someone’s anguish and suffering. Active listening requires us to be disciplined enough to fully concentrate on what the client is saying rather than on the answer that we might have in mind to their situation. Clients experiencing domestic violence require validation — compassionate validation — because many times, their decisions (or lack of them), circumstances and beliefs don’t make sense to us.

Introduce them to mindfulness exercises. Clients experiencing domestic violence live in a world of fear and anxiety because of the cycle of abuse. At first, they’re worried because of their confusion and inability to make sense of and control the incipient abuse. In time, as the abuse increases, worry turns into anxiety and fear.

Mindfulness can help these clients become aware of their emotions, thoughts and bodies to take control of them and find much-needed relaxation. Meditation exercises shouldn’t necessarily be long. There are plenty of sites online with short, simple exercises, from breathing to stretching, that can help clients gain the bodily and emotional awareness they need to function.

Remind clients of their strengths and qualities. One of the benefits of practicing active listening is the ability to notice in clients’ stories what they have forgotten about themselves: their own power, qualities and strengths. By doing this, we help clients not only to survive their circumstances but also to move toward a better future as survivors of domestic violence who deserve lives of meaning and purpose.

Help clients to start a project. Because of shelter-in-place mandates, more perpetrators of abuse are at home all of the time. This increases the emotional state of “walking on eggshells” for domestic violence clients. We can help distract these clients from that state by brainstorming with them or suggesting a project to them. It could be an individual project based on their abilities, strengths and qualities that we noticed in their stories, or it could be a project that involves their children.

Assist clients in making a safety plan. Making a safety plan is incredibly useful. It doesn’t need to be complicated or lengthy. The simplest way of doing this is by helping these clients become aware of their circumstances (call the problem what it is — domestic violence). The rest of the plan might involve:

  • Trying to avoid conflicts and arguments during the mandated confinement
  • Involving their children in most of their home activities
  • Reaching out to relatives and trusted friends (when possible)
  • Being prepared to leave at any moment (i.e., having money, documents, car keys, children’s backpacks filled with some clothes and snacks ready to go)
  • Calling 911 when they feel that they or their children are in danger (even in a shelter-in-place situation, law enforcement will issue an emergency protective order to separate victims from their abusers)

Involve others. We can help our clients experiencing domestic violence to think about the resources they possess to deal with their situation. One of these resources could be men who are part of the couple’s life in some way (e.g., clergy, friends, relatives, co-workers, classmates, teachers, bosses).

When families and friends get involved, perpetrators of abuse can sometimes be dissuaded from causing harm to their partners and children. The presence of fathers, brothers, neighbors and friends prompts accountability. Some of these individuals might be willing to offer their support and speak up against the ongoing abuse. Victims of domestic violence can only break their silence and become survivors if they feel supported. We need to be cautious, however, and see each client in their particular context, giving consideration to whether this type of intervention could put them in more danger than they already are.

Help clients build a network of support. Isolation is one of the most critical signs of abuse. It creates a hated dependency on the abuser. Imposed isolation robs victims of domestic violence of their personhood. It suppresses their voice and identity piece by piece as family members and friends are pushed away. Connections are the simplest way to beat domestic violence. It is critical that victims of domestic violence get reconnected with relationships they trust. It is also crucial to get these clients connected with other survivors of domestic violence (via online groups) so they can claim their victory and begin the journey of healing from the trauma caused by the abuse.

Inspire clients to pursue self-sufficiency. Studies show that when women’s wages are relative to those of men in dual-income couples, there is a significant reduction in domestic violence. To be self-sufficient is to have bargaining power. It’s to have the ability to exert influence in the relationship. There are public resources designated to help survivors of domestic violence pursue further training and education with the purpose of becoming self-sufficient. Check with social services agencies about these resources.

These recommendations aren’t intended to override the urgency of calling 911 when someone is facing a clear and present danger at home. Let law enforcement personnel figure out how they will bring individuals and families to safety during shelter-in-place situations. Emergency protective orders are being issued even with the courts closed.

 

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Federico Carmona is a trauma therapist for victims of domestic and sexual violence at Peace Over Violence in Los Angeles. He is also an ordained elder in the United Methodist Church. The experience of domestic abuse in his ministry and his own family motivated him to seek specialization in clinical counseling, specifically in trauma, to assist survivors of domestic and sexual abuse and violence to reclaim their identity, peace, and lives with dignity and purpose. Contact him at federico@peaceoverviolence.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.

How do counselors support clients during the coronavirus pandemic?

By Yoon Suh Moh and Katharine Sperandio April 9, 2020

It is impossible to deny the extraordinary societal impact of the outbreak of the novel coronavirus, severe acute respiratory syndrome 2 (SARS-Cov-2). All of us are bombarded daily with messages and information related to the pandemic. As this virus garners heightened attention from the media, individuals may have difficulty delineating between misinformation and accurate information about the illness.

We are not writing this article to perpetuate increased fear among the counseling community regarding the spread of the novel coronavirus, but rather to:

  • Provide resources helpful for staying informed about the impact of COVID-19, which is a disease caused by SARS-Cov-2
  • Inform counseling professionals about how they can support clients affected by the virus and its societal impact

What does this outbreak mean to our clients?

It is crucial to understand the social ramifications perpetuated by this outbreak so that we can promote optimal care for the clients we serve.

Individuals who identify as East Asian or appear to be of East Asian descent may be susceptible to experiencing elevated levels of stress related to racism and xenophobia generated by misinformation about the virus. The negative impact on affected individuals ranges from financial and emotional to physical. For example, CNN reported that individuals who appear East Asian have fallen victim to verbal and physical attacks triggered by misguided fears of the infection. Additionally, individuals may be quarantined as a result of suspicions that they have been infected, leading to further stress. Clients who are directly impacted by this wave of racism and xenophobia may experience a vulnerability and lack of safety, perpetuating stress- and trauma-related symptoms.

Although the economic impact of this pandemic has since spread throughout the restaurant industry (and other industries), many Chinese establishments, such as restaurants, were among the first to experience a major decline of business even before community mitigation plans were announced. The financial hit on these establishments has been catastrophic for owners and their families. We must be ready to employ the proper interventions and responses to promote clients’ perseverance, resilience and well-being throughout the tensions that plague our society.

There is no doubt that the novel coronavirus poses a major threat to the entire U.S. economy and the health of our nation as a whole, but concerns are more pronounced among certain populations. For instance, the Pew Research Center reported that approximately 65% of Latinx adults say the coronavirus outbreak is a major threat to the health of the U.S. population as a whole, compared with about 47% of the general public. The same source reports that the outbreak has the potential to hit many of the nation’s nearly 60 million Latinos/as particularly hard. This is in part because a significant percentage of these individuals work in leisure, hospitality and other service industries and have less likelihood of having health insurance.

Of course, many individuals in the general public are fearful (or may become fearful) of contracting the virus. The anticipation of the potential long-term effects of the virus can trigger individual fear and stress-based responses. In addition, an array of compounding or simultaneous stressors can negatively affect individuals’ stress response systems in a chronic manner, meaning that there is no break to return to a healthy physiological state and functioning. These compounding or simultaneous stressors may include:

  • Uncertainty about what might happen next to one’s life and health
  • The exponential curve of virus-confirmed cases and deaths in the nation as reported in the media
  • No access or difficulty in accessing health benefits
  • Financial constraints due to a recent job loss caused by the pandemic

Stress-based responses may be worsened among those who lack resources such as social support.

This brings us to the reality that many states and communities have executed states of emergency, prompting individuals and families to enter into social isolation. Considering the potential negative psychological effects that may be manifested by social isolation, mental health professionals must be ready to intervene and provide support.

Social distancing, taken as a preventive measure to slow the spread of the disease, largely compromises individuals’ daily functioning. People are experiencing disruptions not just in the areas of employment and schooling but also in accessing emotional support from others or even in having regular interactions with others. Individuals who may not have access to technology to virtually stay connected with significant others for emotional support are especially susceptible to social isolation. Social isolation is a risk factor for a number of health-related concerns, including depression.

As the virus continues to ravage communities around the world, it is also important to note that people everywhere are experiencing the loss of their prepandemic normalcy. As a result, many individuals are having feelings associated with grief. Although this pandemic is hypothesized to be temporary, the impact on lives may be much longer term.

Consider that many nonessential businesses have closed their doors, leaving employees without work or a sustainable income to support their families. Most individuals at this point are restrained from engaging in social endeavors such as participating in team sports, attending classes, visiting museums or engaging in other fun-related activities. Most people can no longer meet up with friends or family for regular social events and may feel a sense of loss as their former routines vanish. Social distancing has also called for the cancellation or postponement of important events such as college and high school graduations, preventing new graduates from sharing in a momentous celebration with one another.

Furthermore, the mortality rate associated with COVID-19 continues to rise. People around the world are experiencing the deaths of loved ones and fellow community members. Additionally, family members are assuming the role of caretakers as their vulnerable loved ones fall ill to the virus. As the responsibility to care for loved ones increases, individuals may have to forfeit or abstain from other regular tasks and duties.

Recommendations for counselors

Anxiety management: It is understandable that clients may feel anxious about this situation. Counselors should normalize and validate clients’ fears. Counselors should also talk to clients about factors that they can and cannot control. Some factors that clients can control include getting regular exercise, making plans to meet with friends and loved ones over virtual platforms, determining their exposure to news sources, practicing good personal hygiene, and limiting the time spent in places such as grocery stores where there may be larger crowds.

If clients appear stressed and anxious about the situation, it is a good idea for counselors to help them gain the facts so that clients can accurately determine their risks in collaboration with their health care providers and take reasonable precautions. Additionally, it is ideal to assist clients in developing and enhancing adaptive coping skills, such as grounding techniques or breathing exercises, so that they can effectively manage their anxiety.

Information giving: It is important that counselors stay aware of the latest information available on the COVID-19 outbreak through their local public health authorities and on websites such as those from the Centers for Disease Control and Prevention.

In addition, the World Health Organization (WHO) frequently publishes coronavirus disease situation reports to provide updated information on the outbreak in the world. The WHO website also provides reader-friendly infographics and videos pertaining to protecting yourself and others from getting sick, coping with stress during the pandemic, practicing food safety, and staying healthy while travelling.

Neuroscience News & Research from Technology Networks has provided a short, layperson-friendly video clip titled “What actually happens if you get coronavirus?” that describes how the coronavirus affects the human body.

Counselors should also encourage their clients to stay informed by providing the aforementioned resources.

Culturally responsive service in clinical practice: Counselors can serve as protective and promotive factors when working with individuals who are either directly or indirectly impacted by the coronavirus. Counselors can promote the well-being of clients through the establishment of safety in the therapeutic process and providing them with the opportunity to process the implications of this societal issue. Additionally, counselors can facilitate the process of healing and assist in mediating factors that contribute to individuals’ vulnerability and risk. Therapy can be the catalyst for clients’ adaptability to stressors and adversity brought on by the anticipation of potential consequences from the spread of the virus.

It is crucial that counselors uphold the ethical principles of the profession, including beneficence, nonmaleficence, veracity, justice, fidelity and autonomy, when working with clients. Counselors must be attuned to clients’ well-being and do no harm, as well as treating all individuals fairly and justly. Counselors must normalize and validate clients’ concerns while also providing accurate psychoeducation (not only to our clients but also to the rest of our communities).

Counselors should also be aware that certain ethnic groups, such as those of East Asian descent, may be experiencing additional stressors. President Donald Trump has repeatedly referred to the novel coronavirus as the “Chinese virus” because of its origin in China. We believe such language has contributed to the significant and disproportionate number of verbal and physical attacks on individuals of East Asian descent living in the United States.

We encourage counselors to address these social and societal challenges with these clients, including how such challenges may be affecting their well-being. Counselors should be ready to advocate and provide a voice for individuals who may be marginalized and oppressed due to the societal impact of the outbreak.

Conclusion

Our hope is that this article will give professional counselors and counseling students an opportunity to educate the community with accurate information regarding the COVID-19 pandemic. Furthermore, we hope that professional counselors are informed and effectively equipped to provide support for clients who are affected by the virus and its societal impact. Finally, we encourage all counseling professionals to partake in preventative measures against further expansion of COVID-19 in the nation. After all, prevention is one of the philosophical cornerstones of the counseling profession.

 

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For more on this topic, check out the article “Coping with the (ongoing) stress of COVID-19” from Counseling Today‘s June magazine.

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Yoon Suh Moh is an assistant professor in the community and trauma counseling program at Thomas Jefferson University in Philadelphia. As a licensed professional counselor, national certified counselor and certified rehabilitation counselor, her primary areas of clinical and research interest include the effects of chronic or toxic stress on mental illness, wellness of counseling professionals, and integrative, healing-centered approaches such as neurocounseling. Contact her at yoonsuh.moh@jefferson.edu.

Katharine Sperandio is an assistant professor in the community and trauma counseling program at Thomas Jefferson University. Her main areas of focus include addictions counseling, counselor education, addictions and family systems, and social justice issues in counseling. Contact her at Katharine.Sperandio@jefferson.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.