Monthly Archives: November 2020

DXM: A drug in plain sight

By Emily Weaver, Sharon J. Davis and David Saarnio November 10, 2020

We are writing this article to raise awareness among parents and counselors about a legal and easily accessible drug that is widely used by adolescents to get high: dextromethorphan (DXM). DXM is an ingredient found in certain medications meant to help us get better, so teens frequently abuse this drug without being aware of the potential consequences and dangers. Given the personal insights and experiences we have with the damaging effects of DXM, we are sharing this story in hopes of reaching a larger population and creating more efficient prevention strategies related to teen drug use.


When co-author Sharon Davis’ son was 17, he began abusing over-the-counter (OTC) cough medicine. He had been using marijuana and K2 (synthetic marijuana) for a few years, but it was Coricidin — a cold medicine marketed as being for people with high blood pressure — that really damaged him.

Sharon’s son became a different person. He had always been a moody kid, but his moodiness turned to anger, mania and psychosis. Over a four-month period, his father and mother took him to the emergency room four times. It wasn’t until he attempted suicide that they really got him the help he needed and found out the full extent of his addiction.

He had been introduced to Coricidin through some friends. Soon he was using 30 pills at a time. Coricidin use led to cocaine use. Cocaine use led to methamphetamine use. Two years later, he is working on recovery, but his mind and mental health will never be the same.

According to the Partnership for Drug-Free Kids, 50% of American teenagers have misused a drug, and drug overdose is the fourth-leading cause of death among teens. Parents, counselors and other adults are well aware of the problem of teen drug use, and the nation’s opioid epidemic has brought the topic of medication misuse to the forefront of public attention. That attention is long overdue. However, that focus also misleads us because other critical concerns are being overlooked.

For example, our society is largely neglecting to talk about the large-scale problem of adolescent misuse of OTC medicine and its potential as a gateway to other drugs. In fact, OTC cough and cold medicine is one of the most popular drugs that youth use to get high. According to the Monitoring the Future survey funded by the National Institute on Drug Abuse, more teens got high from OTC medicine in 2019 than from prescription opioids.

Why OTC?

OTC cough medication is easy for teens to get. In some places, teens can purchase these medications from their local convenience stores. Furthermore, most stores have these medications out on the shelf where they are easy to steal. Teens can also get them from peers and even from parents. Because they don’t necessarily perceive these types of medications as “dangerous,” many parents will store them in an unlocked medicine cabinet, unknowingly allowing their teens easy access to them.

The psychoactive drug in OTC cough and cold medicine is DXM, which falls into a class of drugs known as dissociative hallucinogens. Other drugs in this category include PCP, ketamine and nitrous oxide. The Food and Drug Administration (FDA) approved DXM as a cough suppressant in 1958. It remains legal to buy and use in the U.S. DXM is a safe drug when used as directed, but when used in 10 times or more the recommended dose, it acts as a powerful dissociative, distorting reality. Currently, 85%-90% of OTC cough medications contain this effective antitussive (cough inhibitor). DXM is a synthetic opioid drug, but it activates different opioid receptors in the brain than prescription opioids do.

Teens typically misuse DXM to feel the euphoric, dreamlike experiences and hallucinations it causes. When individuals use DXM to get high, they experience various levels of inebriation, known as plateaus.

There are four plateaus associated with DXM. The first plateau involves mild intoxication and stimulant-like effects. The second plateau features increased intoxication and mild hallucinations. At the third plateau, the user enters a state of altered consciousness with impaired senses and psychosis. The fourth plateau involves a sense of derealization (in which the world appears unreal) and depersonalization (e.g., detachment from the self).

Users describe the higher plateaus as akin to being in other realms or alternate universes. Commonly, users feel an out-of-body sensation, like being transported to another dimension. They lose their sense of self and time. It is common for users to post videos or blogs about their experiences, including what they felt like and what they saw while high. The slang term robo-tripping is how many teens refer to being high on DXM. Slang terms for the drug itself include triple-C’s, robo, skittles, red hots and dex.

Why is DXM problematic?

DXM is a dangerous drug when used outside of therapeutic doses, yet little has been done to curb its misuse among teens. For decades, we have known about the consequences of misusing this drug, including seizures, hyperthermia, tachycardia, psychosis, mania and even death.

The opioid epidemic in this country is a national crisis. It is worthy of public attention and government funding to address. At the same time, DXM misuse among teens is also startling, and yet it is rarely highlighted. This drug is more popular than opioids among young people, and it is legal, inexpensive and easy to get.

It is imperative that prevention efforts and policies address this problem. For example, laws similar to those passed in 2005 that required pharmacies to move the popular methamphetamine-making drug pseudoephedrine behind the counter could make DXM less readily available. Some states already require purchasers of OTC cough and cold medications containing DXM to present an ID proving they are 18 or older. We believe this should become mandatory nationwide and that sellers of these drugs should be held accountable.

Furthermore, mass awareness campaigns targeting parents, teachers, law enforcement and counselors need to remind adults of the dangers of these drugs, whereas prevention programs for children and teens should increase their focus on the dangers of OTC medications. National campaigns and policy changes are called for, but these alone will not likely be enough to cause real change. True prevention efforts require work on multiple levels — from the policymakers in Washington to counselors and parents in local communities. Each of us has a part to play, and each can make a difference.

Where do teens hear about DXM?

In today’s era of prolific internet and social media use, teens have more access to the world than ever before. In past decades, peer pressure to use drugs was a huge concern. It was thought that susceptible teens would be influenced by their peers in the neighborhood and at school. This peer pressure occurred face to face.

Today’s teens still confront in-person peer pressure, but they now also face this pressure virtually. Peer influence can come not just from the local teens at school but from millions of teens across the world online. Many teens access the internet and find out about drugs of abuse, including how to get high on OTC cough and cold medications.

A quick search of popular sites such as YouTube can lead teens to videos that either warn of the dangers of DXM or encourage users to experience the high from it. Unfortunately, many websites include dosing recommendations and “tripping” suggestions for having a better experience of getting high.

For example, Reddit, one of the most popular social media sites around the world, has an estimated 430 million active users. Reddit consists of threads that allow its users to post about certain subjects and topics. These threads are like cybercommunities made up of members who hold similar interests. One of these threads, called “r/DXM,” has more than 31,500 users. This thread allows people a place to describe their DXM highs and the side effects. It also provides advice on how to minimize certain side effects such as nausea.

Other websites and cybercommunities such as and the Vaults of Erowid provide teens outlets to post about their DXM highs and get advice from other users on how to use the drug. The site allows users to enter their weights and get a recommended dose for the “plateau” of high they want to achieve. Although many of these websites claim that their purpose is “harm reduction,” teens typically use these sites for suggestions and advice on the “safest” using pleasures. All of these websites are accessible to teens, and all of them are free to use.

Prevention efforts

Fifteen years ago, the FDA issued warning labels on OTC cough and cold medications aimed at making parents aware of the dangers of medicine abuse by teens. The Stop Medicine Abuse campaign launched nationwide in 2004, but clearly that campaign was not successful. More needs to be done to dissuade youth from abusing OTC drugs.

As counselors, we need to step to the front lines of true preventive efforts. This means that we need to know more about DXM (and other OTC medications), the reasons teens are using it, the ways teens are getting it and the most effective methods to prevent its misuse.

Getting parents involved is a good first step. Parents must know what to look for and how to talk to their teens about OTC drugs. Counselors need to get the message out to parents to be realistic and truthful when educating teens about DXM. Scare tactics do not work for many teens; in fact, they may make teens more curious about experiencing the outcomes for themselves. A better approach for prevention may be for parents, family members and other adults to increase the quality of their connection to and communication with youth.

Research shows that establishing consistent messages against drug misuse and having clear boundaries early on can be among the best prevention efforts for teen drug use. Simple steps, such as hiding medications and taking inventory, can also be effective. Most parents want to trust their teens, but having medications that contain DXM where teens can access them is not wise, and many parents are not aware of the dangers of DXM medications. OTC cough and cold medicine should be as securely stored as opioid prescriptions.

In addition, parents need to know what sites their teens are accessing online. A parallel line of defense involves checking browser histories and having clear rules about what teens can access online. Drug use is a leading cause of death among teens (resulting in more than 5,000 deaths per year according to figures from the National Institute on Drug Abuse). Parents wouldn’t want their teens searching for firearms or lethal poisons online, and no parent should want their teen searching for how to get high from DXM. Parents may not be comfortable with this advice. After all, it may feel like snooping, and teens are likely to resist as well. Even so, what teens access online can be one of the biggest telltale signs of drug use.

Establishing rules for computer/internet usage (e.g., allowing a teen to use the internet for two hours a day after completing homework), installing a firewall and setting locks or passwords for downloads can all be safety measures that contribute to prevention or, when needed, intervention. The earlier that parents establish household internet rules, the better. Proactive planning and putting rules in place before children reach their teen years may prove much easier than trying to establish new rules once teens are in late adolescence.

Talking to teens about drug use is often uncomfortable for parents. Many parents do not know where to begin. Some parents are worried that talking about drugs will increase their children’s curiosity about using. Other parents simply find the topic embarrassing or awkward. As counselors, we need to help parents develop communication skills with their children and teens, but especially starting in middle childhood. Counselors can provide parents with resources for where to find information about drugs of abuse, and we can intervene if a teen has already started using. It is almost a certainty that teens talk to other teens about getting high on OTC cough and cold medication. As counselors, we need to encourage parents to talk to their children about choosing not to get high on it.

If Sharon Davis, as both a counselor and parent, had recognized the signs of DXM abuse in her son, he might have gotten help sooner. The message we want parents and counselors to hear is that DXM is one of the most popular drugs for teens, and despite it being legal and easy to get, it is not safe when misused. Sharon was unable to prevent all the damage done to her son, but we hope that her story will help parents of children and teens across the country to protect their own sons and daughters.



Emily Weaver is a graduate student in the clinical mental health counseling program at Arkansas State University. She plans to graduate in the spring, become a licensed professional counselor and pursue a career in addictions counseling. Contact her at

Sharon J. Davis is a professor at Arkansas State University and a certified rehabilitation counselor. Contact her at

David Saarnio is a professor of psychology at Arkansas State University with a specialty in developmental psychology.


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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.

@Tech Counselor: Fighting the fake news and misinformation onslaught

By Adria S. Dunbar and Meghan Manfra November 6, 2020

Unplugging is hard. So much of our lives are tied to technology. We use it to manage our schedules, to keep up with our social acquaintances, to research our questions. The important, the urgent, and the things that can wait all reach us in a similar way, making it difficult to differentiate between the three.

Unplugging means disconnecting from our people. At a time when there is already so much social distance in the world, the idea of unplugging can feel overwhelming or impossible. For most of us, the positive aspects of social media certainly outweigh the negative ones, so it is more important than ever that we consider our own media literacy to differentiate facts from fake news and misinformation.

Our online identities are an extension of ourselves, so it is not surprising that the way we interact online, and our exposure to online content, impacts our sense of self in real life. As a country, we are experiencing a vulnerable time in which people are unsure who or what to trust, particularly online. Anxiety, depression and substance use are all rising during this global pandemic, and online misinformation campaigns have the potential to exacerbate symptoms for some clients. Counselors might find themselves in situations where they need to address clients’ mental health concerns without straying too far into politics.

Here are some recommendations and resources that might help counselors in this work, particularly over the next few weeks or months, as the results of one of the most contentious elections in American history draws to a close. Regardless of our political leanings, our ethical responsibility to empower our clients toward wellness creates a need for new media literacy tools in our toolboxes.



Read laterally: Use fact-checking sites like to research news items and social media posts. They can usually tell you if the item is misinformation, malinformation (i.e. propaganda) or an outright hoax. For example, search Snopes for “shark on highway after Hurricane Harvey in Texas.”

Conduct a reverse image search: Hover your mouse over the image, right click on the image and select “search Google for image.” You will see other places the image has been used. Again, you will find out pretty quickly if the image is credible.

Determine the perspective of the source: Look for the “about us” page. Keep an eye out for “paid content.” And, when visiting news sources, look for their editorial ethics page.


The following resources can help you strengthen your social media skills:

  • Pew Research Center —- A nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world
  • The Sift —- A free weekly newsletter published by The News Literacy Project, a nonpartisan national education nonprofit, that explores timely examples of misinformation, addresses media and press freedom topics and discusses social media trends and issues
  • Spot the Troll — An interactive game that allows players to read a brief selection of posts from a single social media account or “profile” and then decide if each is an authentic account or a professional troll. After each profile, you’ll review the signs that can help you determine if it’s a troll or not.
  • Lamboozled: The Media Literacy Card Game — A card game designed to help youth develop media literacy skills.

Image from the United Nations COVID-19 response page at


@TechCounselor’s Instagram is @techcounselor.

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

Meghan Manfra is an associate professor in the Department of Teacher Education and Learning Sciences at North Carolina State University. She lives in Raleigh with her husband and two daughters. 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.

Integrating substance dependence and pain management into counseling approaches

By Geri Miller November 5, 2020

In the United Sates, 2000-2010 was labeled the “decade of pain.” In 2011, the Institute of Medicine’s Committee on Advancing Pain Research, Care and Education stated that the prevalence of chronic pain in our country exceeded the prevalence of diabetes, heart disease and cancer combined.

Unfortunately, this prevalence of pain has continued, and because of that, counselors need to be aware that substance dependence and pain management may be an issue for their clients — even if it is not a “problem” as presented by clients themselves. Clients may be particularly vulnerable to substance dependence specific to opioids because they (or others in their lives) may view these drugs as the best treatment for pain (i.e., a “quick fix”).

There is a great deal to know about substance dependence and pain management. Because of this, counselors can easily become overwhelmed and hesitate to work with these issues. I am writing this article to help counselors see that they can readily integrate some basic substance dependence and pain management approaches into their current counseling practices and still be practicing within their area of competence.

Because of the prevalence of substance dependence and pain management in the United States, it would serve counselors well to always “wear the lenses” of both of these areas as they assess and treat their clients. However, it is probably most important for counselors who are working with clients specifically on either one of these two areas (substance dependence or pain management) to also intentionally explore the area not presented as a problem so that the potential relationship between the two is examined. For example, when counseling someone who struggles with chronic pain, a counselor would be well advised to also ask about their substance use. The same exploration needs to happen when a client struggles with substance dependence; a counselor should ask about any issues with pain and its management.

While this exploration is important, it is also imperative for counselors to be able to readily fuse these “lenses” into their existing clinical approaches. Five suggestions on the general process of incorporating these two perspectives follow.

First, counselors need to accept the reality that there is a lot to know about substance dependence and pain management and make sure that they work within their area of competence. One method for exploring and addressing these areas with their clients (while still practicing in their area of competence) is to use the “HOW” approach. This acronym encourages counselors to be honest, open and willing to discuss substance dependence and pain management issues with their clients. For example, a counselor can be honest about not knowing much about the client’s experience of pain, be open to being educated about the client’s perspective and be willing to discuss the pain experience with the client.

Second, counselors can anchor their approach in the discussion with respect for and genuineness toward the client. This client-centered approach inherently invites the client’s story of their pain (including the ways they try to handle the pain, such as opiates).

Third, counselors can assess and treat the pain using their typical counseling approaches and continue reassessment throughout the treatment process. Counselors should operate as gatherers of information about the pain and, as appropriate, consult with others (e.g., mentors, supervisors, colleagues, medical professionals) concerning appropriate ways to address the pain.

Fourth, counselors need to be aware of countertransference related to their own and their loved ones’ experiences with pain management and substance dependence. An awareness of their countertransference can enhance counselors’ effectiveness in addressing these overlapping areas.

Finally, counselors need to work within the realistic resource limitations that both they and their clients experience. For example, both counselors and their clients have limitations on the amount of time, energy and money they can invest in learning about and addressing the issues of substance dependence and pain management. Maintaining such a realistic perspective can cultivate more humane and practical counseling interventions that will result in less frustration for both the counselor and client.

An overview of chronic pain

In 2011, as stated previously, the Institute of Medicine’s Committee on Advancing Pain Research, Care and Education reported that chronic pain exceeded the combination of diabetes, heart disease and cancer in terms of prevalence in the United States. These historical statistics, in which the current issues of substance abuse and pain management are anchored, underscore the likelihood that many of our counseling clients are experiencing chronic pain but have not mentioned it or its impact on their lives in session. This prevalence should serve as an invitation for counselors to discuss pain and pain management with their clients.

In 2019, Beth Darnall, a pain scientist and director of the Stanford Pain Relief Innovations Lab, summarized the following information on chronic pain in her book Psychological Treatment for Patients With Chronic Pain. By definition, chronic pain is pain that lasts longer than three months or that extends beyond the expected time it should take to heal. Breakthrough pain is an acute version of chronic pain and centers on days or times when the pain is worse.

Although Darnall called chronic pain a “harm alarm” that tells the person to escape the pain to survive, she said the “riddle of chronic pain” is that it is impossible to escape. This knowledge needs to be fused into the perspective of how the pain experience is affecting our counseling clients in a biopsychosocial manner. This biopsychosocial exploration of the relationship between the overlapping areas of substance abuse and pain management can be facilitated by the core suggestions presented in the following section.

Core suggestions

I offer seven core suggestions that counselors can use as a guide in addressing substance dependence and pain management from a biopsychosocial perspective.

1) Work out of a systems perspective. From this perspective, the counselor looks at the systemic interactions that result separately for addiction and pain, as well as their overlap systemically. This means that the counselor is aware of the internal and external contributing factors for both addiction and pain and that the client may have developed an addiction in response to their pain or vice versa. The addiction may have resulted from prescribed medication following surgery, or the pain may have resulted from an accident that occurred while the client was under the influence of alcohol or drugs.

2) Watch for prescribed and nonprescribed substance use. This suggestion means that the counselor obtains information from the client about any prescribed medication of substances (such as medication-assisted treatment) in response to their pain or substance dependence as well as the client’s nonprescribed usage of opiates and marijuana for pain. Such an inclusive gathering of information provides the counselor with a broader view of the client’s treatment responses to managing the pain.

3) Practice “compassionate accountability.” This phrase means that the counselor has compassion for the client and simultaneously holds the client accountable for their behavior. For example, I can have compassion that my client has an addiction resulting from their use of opiates in response to chronic pain that prevents the client from performing activities of daily living. However, I also need to hold the client accountable for their behavior, such as stealing prescription opiates from a friend’s medicine cabinet.

4) Use firm, direct, honest communication. This is complementary to exercising compassionate accountability because this form of communication avoids enabling behaviors related to both pain management and addiction. No matter what, clients are responsible for the choices they make, and counselors need to be clear with clients about what they see.

5) Consider a harm-reduction perspective. This perspective means that the counselor walks the fine line of not enabling the client’s substance use while at the same time not requiring the client to suddenly commit themselves to abstinence. Instead, the counselor works within the reality of the client’s willingness and ability to change without encouraging the client to remain at the same level of change.

6) Complete assessment and treatment plans for both addiction and pain. This involves the counselor examining both areas in a broad way that includes the client’s fear of the pain returning and their psychological withdrawal from pain medication.

7) Watch for behavioral indicators of pain during the session. A significant amount of information can be gathered when the client is actively experiencing pain. The client’s pain experience can be processed in the moment, and the resulting information can assist both the assessment and treatment processes.


Counselors can use a simple anchoring assessment prompt to elicit each client’s story: “Tell me the story of your pain.”

That open-ended prompt has the power to draw out narratives that clients have perhaps not spoken about previously. These clients may be accustomed to closed questions or scaling questions regarding their pain, but they may never have had anyone ask about and then carefully listen to the actual story of their pain.

This motivational interviewing approach can readily draw out information about the impact of community, culture, family and multicultural factors on the individual’s self-report. For example, the client may talk about how pain is simply not discussed in their family and culture. As a result, they have learned not to reach out for support to address their pain. The counselor could then help the client develop skills to reach out to others who will be supportive of them as they live with their pain, or the counselor might refer the client to a group that discusses pain management approaches.

Another assessment approach is to have clients keep diaries or logs pertaining to their pain, sleep and nutrition. These logs can assist in obtaining information about pain patterns and contributing factors to pain. Such record-keeping also needs to focus on what the client is doing “right” as well as what they are doing “wrong,” in addition to times when the areas of pain, sleep and nutrition are going well for the client. The collection of this information is solution-focused and strength-based. It can become the cornerstone on which healing treatment is built.

The assessment of pain also needs to be considered within the context of addiction. So, although the client has pain, this does not mean that it is necessary for them to use substances to cope with that pain. Neither does the existence of pain prevent the client from being confronted about their addiction as a “stand-alone” diagnosis.

Thus, the message is twofold:

1) The client can learn to live with pain without the use of substances.

2) The client may need to be confronted solely on their use of substances.


Treatment for pain can involve various therapy modalities such as individual, group or family counseling. The counselor and client can choose the modality that seems to best fit the needs of the client, in combination with the resources available related to client income, agency resources and community resources.

Specific therapy approaches can include motivational interviewing, cognitive behavior therapy, acceptance and commitment therapy, and grief counseling (because when dealing with chronic pain, clients frequently have issues of loss). It is within these forms of therapy where clinicians can legitimately practice counseling in their areas of competence by simply anchoring themselves in their treatment approach (e.g., therapy modalities, specific therapy approaches) and adding the lenses of “pain” and “substance abuse” by asking about information in the assessment process that broadly addresses these areas. Such broad assessment can assist the counselor in knowing whether the treatment of pain and substance use can be readily integrated into treatment or whether a more specific assessment and focused treatment of these areas are required.

Treatments that change the client’s relationship with the pain by focusing on the present (e.g., mindfulness, yoga, biofeedback, acupuncture) are also potential resources. In such cases, clients may remain aware of the pain but work with the knowledge that the intensity of their pain ebbs and flows and learn how to live with that process. They may also find techniques to reduce their pain.

Another treatment approach, described by Kirsten Weir in 2017 in Monitor on Psychology, encourages the client to practice self-care of the body through diet, exercise and sleep. It uses the metaphor of a stool with three legs. I developed the diagram above for the fifth edition of my book Learning the Language of Addiction Counseling (currently in press) to illustrate this metaphor.

The three-pronged stool is precariously balanced, which illustrates that self-care is not a static entity but rather one that needs to fluctuate depending on the client and the context. Each leg of the stool (diet, exercise, sleep) is needed to keep the overall stool (self-care) in balance. In other words, each leg has an impact on the others. For example, the experience of pain may negatively affect a client’s sleep, which then inhibits them from exercising and tempts them to eat unhealthy comfort foods. In contrast, a client who gets enough sleep may experience diminished pain, thus encouraging them to exercise and practice healthy eating. Counselors need to remind clients, however, that “pretty good” self-care is good enough; one does not have to practice “perfect” self-care to reap the benefits.

A final treatment approach involves counselors viewing themselves as part of a health management team. Such a team can consist of different health care professionals in which each professional has an important perspective on the unique aspects of the individual client’s pain and pain management. The unique components of the client’s pain determine the composition of such a team and the treatment system in which the team exists (e.g., hospital setting, private practice). Whether the team is formally or informally established by the counselor or by the system in which the counselor works, the counselor provides a critical mental health perspective that is needed for a holistic treatment approach.

As part of such a team, counselors familiarize themselves with any prescribed medications that the client is taking for chronic, active disorders. Counselors then play a role in the planned and gradual reduction of medications being taken. Counselors do not need to be experts in pain management or medications to be part of such a team or to be assigned to a formal team. The team approach can be extremely effective in serving the welfare of clients.

The counseling perspective offers important contributions to such teams, including a heightened sensitivity for clients’ pain stories and a commitment to advocating for clients. Such a perspective can result in an effective and humane approach to pain management and the use of prescription drugs. Additionally, this perspective can prevent clients from feeling like they are being dehumanized on a “medical assembly line” during the treatment process.


Clinicians can work effectively with clients by integrating pain management and substance use approaches into their already-existing counseling approaches. Awareness of the prevalence of chronic pain and its potential interaction with substance use can assist counselors during the assessment and treatment process.

Chronic pain and substance use frequently overlap, but they are areas that can easily be missed in terms of their impact on clients’ presenting problems. Simply by integrating the lenses of pain management and substance use into their counseling — asking questions and intervening as necessary — clinicians can offer a more holistic approach to their clients.

The development of these lenses can be enhanced through continuing education, ongoing training and staying informed on current research. There are some excellent resources (see below) that counselors can add to their clinical toolboxes. Counselors who commit to more deeply examining the areas of pain management and substance use can improve their overall treatment effectiveness and, thus, act in the best interests of their clients.

Recommended resources


Learn more: ACA has produced a series of webinars with Miller on this topic. See more at ACA’s Professional Development Center:


Geri Miller is a licensed professional counselor, licensed clinical addiction specialist, certified clinical supervisor, master addiction counselor, licensed psychologist, diplomate in counseling psychology and a professor in the Department of Human Development and Psychological Counseling at Appalachian State University. She has worked in the counseling profession since 1976 and in the addictions field since 1979. She has published and presented research on counseling, and the fifth edition of her book Learning the Language of Addiction Counseling is currently in press. Contact her at


Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.


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 in the trenches

By Lindsey Phillips November 2, 2020

Adrian Marquez, a retired Marine master sergeant and  Marine Raider, woke up one morning during his time in the Marine Corps and couldn’t remember how to get dressed. He looked down at his pile of clothes and mumbled, “Pants first, then shoes?”

Marquez was also experiencing physical aches throughout his body, including radiating pain in his arms and legs. His left arm would sometimes lose strength and go numb. So, he went to his unit’s medical clinic — a team of primary care medical doctors, psychologists, psychiatrists, social workers and physical therapists — and the medical staff told Marquez he was physically healthy compared with peers in his age range across the United States. They determined it was all in his head. The mental health clinicians made assumptions based on Marquez’s extensive combat history and quickly diagnosed him with posttraumatic stress disorder (PTSD), an anxiety disorder and a depressive disorder with severe somatic symptoms.

But the symptoms didn’t go away. Marquez later returned to the clinic because of intense pain in the back of his left eye. This time, the clinic performed an MRI and discovered that he had ocular damage, in addition to possible injuries to his brain. Another MRI was scheduled, and it confirmed that Marquez had a traumatic brain injury (TBI) that caused lesions across his brain, including one in his orbital track. The scan also picked up another issue: Marquez had four compressed disks, two of which had ruptured, so even a moderate impact would lead to paralysis.

Despite his injuries, the Marine Corps insisted that Marquez get ready to deploy again in a few weeks’ time. Learning this, his master gunnery sergeant pulled him aside and told him, “There will be a time when you take your uniform off, and you’re going to have to live with the person underneath it. If you want to have a normal life, you have to take care of yourself.”

The master gunnery sergeant sent Marquez’s paperwork to the Wounded Warrior Regiment, which allowed medical staff to fully evaluate him for a month. According to Marquez, the master gunnery sergeant lost his position over that decision, but Marquez took what his “master gunns” said to heart. During the evaluation, Marquez concluded that he needed to take care of his physical and mental health before deploying again. When he told his new master gunnery sergeant that he wanted to have surgery before deploying, the Marine Corps forced him into medical retirement.

The decision shook Marquez to his core. He had given the Marines 17 years of his life, and now he was left to deal with abandonment issues, depression and anxiety — on top of his physical injuries and TBI. When he started mental health therapy, he quickly realized that the clinicians treating him were knowledgeable about mental health issues, but they didn’t seem to have much of an understanding about military culture.

Improving military cultural competency 

Marquez is now a licensed mental health counselor himself. He created and serves as the director of programming for the Sheepdog Program, a mental health and substance abuse program for veterans and first responders in Melbourne, Florida. The fact that he encountered so many mental health clinicians who were not culturally competent about the military is not shocking given that many practitioners lack specific training in that area and don’t necessarily consider clients who serve in the military as being part of a distinct culture.

But as Marquez points out, the military does indoctrinate people into a unique culture — one that is fast-paced and possesses its own rules, policies and language. Being in the military changes the way that people think and feel, Marquez emphasizes. He compares this new mentality to being a sheepdog because, he says, service members are trained to stand outside and protect the herd by leaving the herd and staring into the eyes of the wolf. They can’t and don’t hide from the ugliness of the world. Instead, they are often exposed to a raw violence. And once exposed, they can’t unsee it, Marquez says. It is imprinted in their minds and shapes the way they view the world.

Keith Myers, dean of clinical affairs and an associate professor of counseling at Richmont Graduate University, conducted interviews with veterans for his recently published book, Counseling Veterans: A Practical Guide, which he co-authored with W. David Lane, a licensed professional counselor (LPC) and professor of counseling at Mercer University. In doing the interviews, Myers says that one topic kept coming up repeatedly: the need for counselors to be culturally competent with this population.

Just like with any other cultural group, counselors have to learn the specific language and customs associated with the military culture, says Taqueena Quintana, an American Counseling Association member and owner of Transformation Counseling Services, a private practice that works with military-connected populations. The language is also specific between military branches, she points out. For example, calling someone in the Air Force a “soldier” communicates a lack of understanding and can cause offense because they are properly referred to as “airmen,” she explains.

Counselors also need to consider these clients’ personal cultural factors — ethnicity, sexual orientation, spirituality, era of service and so on — that further shape their experience both during and after military service.

“Veterans are not cut out from the same material,” notes Tanya Workman, an LPC who is the training director for the licensed professional mental health counselor training program at the South Texas Veterans Health Care System’s Frank Tejeda Outpatient Clinic in San Antonio. “Their overall life experiences, as well as their experiences in the military, will potentially shape their perspective and response to treatment. So, take time to understand the impact that the veterans’ time in service has contributed to their current mental health and function.”

Workman advises counselors to learn about military culture, the various branches of service, the history of the different eras and the veterans’ perceptions of the role they played while in service. Showing interest in the veterans’ experiences builds rapport and helps avoid unintentionally creating barriers by assuming to know what that experience was like for them, she continues. For example, if a veteran is struggling with a moral injury, they may find it difficult to respond to a therapist’s expectation that they are proud of their time in service, she says. So, Workman recommends counselors ask clients, “Why did you join the military? What did your time in service mean to you? What feelings come up regarding your time in the military?”

When she has clients who have retired or finished their time in service, she always asks about their transition from military to civilian life and whether they were ready to retire or separate from the military. Some are ready to be done, she says, but others may feel their time was cut short because of administrative, disciplinary or medical reasons (e.g., not making a designated rank within a specified time period, incurring a medical or mental health condition that prohibits the service member from doing their job). Processing their feelings (such as loss or grief) related to the sudden end of their service can be validating and helps set the tone for future healthy disclosure, she adds.

Myers, an LPC with a private practice serving veterans in Marietta, Georgia, recommends that counselors start by talking to relatives or friends who are veterans and asking them, “What was your experience like? What’s your advice for me as a counselor who wants to work with this population?”

Making counseling relatable

When counselors learn more about clients’ occupations and experiences in the military, they are better able to connect counseling activities and concepts to things that are relatable to the clients, advises Workman, an Army veteran and ACA member who specializes in treating veterans dealing with trauma (including military sexual trauma), substance use disorders and difficulties transitioning from military to civilian settings. For example, she equates the importance of breathing techniques with running and calling cadence or being at a rifle range. All of these activities involve a rhythmic or patterned breathing that some military clients already understand well.

Marquez, owner of the private practice Calm in the Storms, modifies the way he explains mindfulness to his clients. He starts by referring to it as mindfulness training rather than mindfulness meditation. Then he compares mindfulness training to exercise or pistol practice: Clients must repeat the action over and over again for it to work effectively. With meditation, clients are doing a repetitive action — such as focusing on breathing or a certain noise or sensation — to control intrusive thoughts and ground themselves in the present moment, he explains.

Workman, a member of the Military and Government Counseling Association (MGCA), a division of ACA, also uses analogies to explain difficult topics such as hyperarousal, anxiety and avoidance. She often describes hyperarousal as birthday candles setting off smoke detectors and sprinklers to explain how the body’s response to the environment is sometimes more than what is needed. The body — like the alarms — is just responding to a perceived danger. This analogy helps clients understand that hyperarousal is a normal bodily response designed to keep them safe. Then, Workman teaches clients how to be aware of this heightened response and how to calm the body so that the response matches the level of danger.

Marquez also refers to solution-focused therapy as mission-oriented therapy when working with clients affiliated with the military. He describes the approach as a way of addressing the 5-, 10- and 25-meter targets in clients’ lives. He explains that unless the client confronts and takes action on the 5-meter target, it could prevent them from working on their longer-term goals (their 10- and 25-meter targets).

Myers, an ACA member whose clinical specialties include veterans issues, trauma and combat-related PTSD, sometimes makes subtle adjustments to counseling approaches when working with military-connected clients. For example, in couples counseling, Myers often uses John and Julie Gottman’s concept of “accepting influence” from your partner, which involves taking your partner’s opinion into account and being open to using their input to make decisions together.

With military-affiliated couples, Myers brings in a third partner — the military — because the couple must compromise not only with each other but also with the military. When the military deploys the service member or reassigns the service member to a new post, the couple must readjust their plans and deal with these added stressors together.

It’s not all combat-related PTSD

Marquez says he worked with a few therapists who almost did him more harm than good because they assumed that his combat experience was the catalyst for his PTSD. They thought that engaging in military operations and pulling the trigger on his weapon so many times had to be the source of his trauma. They didn’t seem to understand or accept that Marquez was comfortable with the actions he took during his military service.

But one therapist was different. He didn’t presuppose that Marquez’s PTSD was attached to his military service. He set aside his own assumptions and told Marquez, “I can’t pretend to understand what you’ve been through, and I’m not going to. I’m going to ask you questions, hear you talk and connect the dots based on what you say.”

In going through that process with the therapist, Marquez finally discovered that the actual source of his PTSD was his experience of escorting his friend’s body home to Texas. As the escort, he had to view the body and make sure that the uniform was ready for presentation. Seeing his friend’s face — which was almost unrecognizable covered in makeup and saran wrap to preserve the body for the funeral — and confronting the reality of death triggered his PTSD.

Therapists are great at understanding different types of trauma, but some have muddied the water by diagnosing seemingly everything related to the military as PTSD, Marquez adds.

Quintana, an LPC in Washington, D.C., and an assistant professor of counseling at Arkansas State University, agrees that PTSD and TBI are the two mental health issues that people most closely associate with the military. Although a large number of veterans and service members do indeed contend with these issues, they also deal regularly with depression, anxiety, adjustment disorder, co-occurring disorders, substance use disorders, family discord and marital issues, to name a few, Quintana says. Sometimes people connect the military almost exclusively with war and combat, she says, forgetting or not realizing that chaplains, medical professionals and lawyers also serve in the military.

Combat-related PTSD often makes the news, which is good because it raises awareness about mental health and military-connected clients, but it also leads to the common misconception that the majority of veterans have PTSD, says Myers, an MGCA member who previously served on the association’s board of directors. Although PTSD is a common clinical issue, the majority of veterans do not have PTSD. According to the Department of Veterans Affairs, 11% to 30% of veterans have had PTSD over their lifetime.

On the flip side, sometimes clinicians and veterans may assume that certain military service members could not be experiencing PTSD because they have not seen combat in a traditional sense, Workman adds. But trauma is not exclusive to combat occupations, so clinicians should assess all veterans for trauma exposure during service, as well as for trauma that may have occurred elsewhere across the life span, she continues.

For example, she has worked with veterans who served in military intelligence. Their work required them to monitor a computer, and consequently, they were often exposed to the aversive details of violence and war. Even though it would be easy to dismiss their experience as simply sitting in a safe room without the fear of others shooting at them, they still were exposed to combat, just in a different way, Workman says.

Treating co-occurring disorders

Mental health work doesn’t always come neatly packaged with only one presenting problem at a time. Issues often overlap, and Quintana, a deployed resiliency counselor for the Navy, finds that co-occurring disorders are common among military-connected clients.

According to the National Center for PTSD, substance use disorder and PTSD often co-occur with veterans. In the past, mental health and substance use treatment facilities often required clients to be abstinent from substance use before treating them for mental health issues. But this is happening less frequently, and more agencies are taking an integrative approach to care through dual-diagnosis groups, relapse prevention education and comprehensive treatment plans for co-occurring disorders, says Quintana, a member of MGCA and a former school counselor with the Department of Defense Education Activity.

Still, health care professionals too often focus solely on the high intake of substances rather than looking at the big picture or other co-occurring issues, Marquez notes. He says he has known clinics that quickly diagnosed military-connected clients with a substance use disorder and made that the primary treatment plan, or they refused to address trauma at all because they didn’t have the time or resources to handle both the substance use disorder and trauma simultaneously. This experience often causes these clients to either leave counseling or to refrain from talking honestly about their substance use out of fear that they will automatically be labeled with a substance use disorder, he says.

When clients come to Marquez with co-occurring issues such as trauma and substance use, he is honest with them. He informs them that their drinking might technically qualify as a substance use disorder, but he also acknowledges that he knows that behavior is considered acceptable in military culture. He doesn’t ask them to stop, but he does request that they show him that substance use is not a factor in their presenting issue. Often, they stop using substances without any problems. If they don’t, then substance use disorder becomes another part of their treatment plan.

When working with veterans who may have a significant history of alcohol or substance use, Workman advises counselors to be vigilant in looking not just at how much these clients are drinking or using substances but also at their history of trauma, anxiety and other mental health issues. If a person’s anxiety is high and not adequately managed, then it isn’t shocking to find that they are drinking excessively or having difficulty with irritability, anger, or interpersonal interactions at home or work, she says.

Counselors should also do a thorough evaluation if a military-connected client is referred to them for a behavioral problem because, so often, the problem is not the problem, Workman says. “Counselors should ask the veteran, ‘When did this behavior start? What makes it worse? What were you thinking and feeling? What else was going on when you were engaging in this behavior? When was it not like this?’”

It is easy to focus only on the negative behavior, but then the underlying mental health issues that contributed to that behavior often go overlooked and untreated, Workman adds.

Likewise, counselors shouldn’t focus only on the events that happened during clients’ time in the military. Sometimes, past traumas or mental health issues can go untreated, and military experiences only compound the issue. For example, someone who was previously reprimanded for violence might now be applauded and promoted for similarly violent actions performed during their military service. This person is receiving conflicting moral messages, which may compound the emotional wounds they had before entering service, Marquez says.

Co-occurring disorders can also become an issue when symptoms overlap, Myers points out. TBI and major depression can both involve difficulties with attention, depressed mood and trouble sleeping. And irritability and agitation are both symptoms of TBI and PTSD. This overlap can make it challenging to treat, Myers says. Counselors may get stuck trying to figure out the diagnosis — is it TBI, depression or both? “It’s less about deciding what the diagnosis is and more about treating this person holistically,” Myers says.

Marquez says that if counselors focus on a client’s trauma first and wait to address their grief until later, then when they do get around to focusing on the grief, all of the client’s trauma could resurface. That’s why Marquez addresses it all at once. In the Sheepdog Program, which offers a partial hospitalization program and an intensive outpatient program, clients have two to five individual therapy sessions per week, along with other special therapy sessions such as narrative therapy, eye movement desensitization and reprocessing (EMDR), and family therapy that address the specific issues with which they are dealing.

Short-term therapies

Traditional, hourlong counseling sessions aren’t always a possibility for military-connected clients, especially those who are active-duty service members, because they are always in motion, Quintana says. Depending on their duties, some service members may have only a short span of time to meet with a mental health professional, such as during lunch breaks, she points out.

For this reason, Quintana continues, solution-focused therapy, which is a future-focused and goal-oriented approach, can be effective for certain issues within military settings (although not for more serious issues such as trauma and suicidality). If a service member presents with a relationship issue, for example, Quintana empowers the client to identify their own solutions. She may say, “Tell me a time when this issue did not exist. What was different then?” This encourages the client to get away from all-or-nothing thinking and highlight strategies that were helpful previously.

Quintana also believes it is important to build on clients’ strengths. For example, if the client says they are good at communication, she would explore with the client how they could use this skill to improve their relationship. After the client sets goals (with Quintana’s support), Quintana would continue to follow up with the client to monitor success.

Workman fears some veterans may be burned out by solution-focused therapy because it is used so often with service members while in the military setting. In her work with veterans, she uses prolonged exposure for primary care (PE-PC), a type of abbreviated therapy specially designed for the treatment of trauma. It consists of a minimum of six 30-minute sessions provided at the client’s primary care clinic, which tends to be a more convenient and familiar setting for them. This therapy also helps veterans who are not able to dedicate a large portion of their day to counseling and may remove potential barriers to treatment posed by the stigma associated with referral to a mental health clinic, Workman notes.

In these sessions, clinicians teach veterans about common mental health issues such as PTSD. They learn to recognize distressing symptoms and evaluate the intensity of these symptoms by using the Subjective Units of Distress Scale, a self-assessment tool that measures the subjective intensity of disturbances or distress experienced by an individual. Clients track their distress level using this scale before, during and after writing their trauma narrative. By doing this, Workman finds that clients begin to notice improvements in the way they respond to distressing thoughts and memories and that their distress decreases the more they read their narrative out loud. They also have more control and do not experience the same overwhelming symptoms of trauma-related anxiety, she adds.

Clinicians also teach veterans to safely cope with mood distress by using safe grounding and relaxation techniques, Workman continues. The clients work through a prolonged exposure workbook, recording and processing their personal trauma event in a safe and systematic manner with the therapist’s support. The therapist ends each session with a relaxation exercise.

Following this sequence of steps empowers clients to repeat this behavior on their own, she points out. She has found the treatment to be effective, with clients reporting a decrease in severity levels and, more importantly, an improvement in their quality of life.

Marquez finds that virtual reality exposure therapy helps military-connected clients reexperience and remember events connected to emotionally charged memories. Marquez once worked with a client who had dissociative amnesia surrounding an event in which his comrade died in a car. The client felt guilty for not pulling his fellow service member out of the car in time. Marquez positioned the client in front of a black virtual reality screen and asked him to recall the events of that day. At one point, the client described hearing a roar, so Marquez played a few different sounds. When he played a fire sound, the client said, “Yeah, that’s the sound.”

Marquez then turned on the virtual reality screen, and the client saw a vehicle that was on fire. Seeing this image made the client recall that the car had been on fire, so he couldn’t have gone back to save his comrade. The interactive experience restored the client’s lost memories and freed him from the guilt he had felt for years.

Marquez says this therapy helps clients reduce the triggers associated with traditional PTSD responses. It also helps them revisit memories that are often repressed by their military training to react in a rational, nonemotional way. But when they relive the event, they may experience unrecognized emotions associated with it, Marquez points out. So, he uses EMDR to help clients manage the emotional memories that often resurface after virtual reality exposure. “They’re allowing themselves to finally feel the emotions that they never let themselves feel because they were just operating in the rational mind, just following their training,” he explains.

Creating a pipeline for success

Some military families have confided to Quintana that they don’t seek out counseling because they fear they will simply be passed off to someone else or handed a referral list. “Counselors must take time to invest in their clients and ensure they are part of the process,” she stresses.

Quintana takes a collaborative approach with military-connected clients. She believes that partnership is key to facilitating change. In addition to meeting clients where they are, Quintana works with them to highlight their past successes, set goals, and identify tools and resources that can help to address their issues.

Quintana provides an example: A military family is experiencing their second deployment, and the spouse comes to counseling concerned about their child’s social, emotional and behavioral responses to the transition. To better understand this family and their particular needs and strengths, Quintana might explore the family’s past experiences and successes. She might ask the spouse, “What helped your child when they previously navigated challenges related to deployment?” or “Tell me about a time during deployment when this issue was less noticeable. How did you make that happen?” These types of questions help build on what has already worked, highlight the family’s strengths and empower the family to identify solutions.

Through this conversation, Quintana learns that during the previous deployment, the school counselor placed the child in a group with other military-connected children dealing with deployment challenges, and the child found bibliotherapy to be helpful in processing their feelings. Rather than handing the parent a list of resources, Quintana would suggest that the family collaborate with their child’s new school counselor on bibliotherapy strategies that could be used both at school and at home. She would also work with the spouse to access these services within the school and, if needed, the community. “These relationships are meaningful and foster trust, which is critical when supporting military families,” Quintana says.

Myers often seeks to empower his military-connected clients through the use of motivational interviewing. This approach encourages clients to discuss their own reasons and motivations for change. Being able to set their own goals, talk about ways to achieve change and explore their motivations honors their autonomy, Myers says.

Marquez learned the importance of mental wellness the hard way through misdiagnosis and clinicians who were insufficiently trained in the military culture. To correct this issue, he has developed programs and trainings to educate clinicians on working with this population, but he says he would love to see more mental health professionals get involved in creating a pipeline for veterans who want to become counselors and in facilitating peer support specialist groups led by veterans.

Marquez finally found a clinician who took the time to listen and help him figure out the root of his PTSD. Mental health professionals can learn from his experience by becoming more culturally competent and reframing their tools so that military-connected clients do not find themselves alone in the trenches.



Action steps for more information:


Read a companion article to this piece, “Advice for counselors who want to work with military clients,” at CT Online.


Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at or through her website 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.

CEO’s Message: It’s a critical time for self-care

Richard Yep

Richard Yep, ACA CEO

The continuing challenges much of the world’s population is facing are daunting, consuming and overpowering. Here in the United States, the ongoing battle against the coronavirus, critical discussions around racism, and an unconventional national election can drain one’s energy and spirit. Add to that an economy that sees so many people out of work and so many others in a state of food insecurity.

My message to you is that we cannot let all of this overwhelm those who are part of the solution. You are part of the solution. The work being done by professional counselors and counselor educators and the education and training that counseling graduate students are receiving are what give me hope for the world that many of us envision: a world of respect, dignity and inclusiveness.

I’ve said this many times in this column: The counseling profession is so critically important in addressing the challenges that confront clients, students and communities. So, in order to keep going and to help others thrive, I encourage you to continue practicing the basics of self-care. Just as you are passionate about helping others find their way, you must know when it is time to take a break, consult with colleagues or even stop counseling long enough to recharge.

At ACA, we want to help you in your practice, we want to advocate for the profession, and we want to ensure that those who can benefit from your work will seek you out. We can do all of these things, but it will not amount to a “hill of beans” unless we have professional counselors who can practice, teach and supervise. Burn out and we all lose out.

Please take a moment to think about what you do (and what you tell others) about self-care. Search the internet for new ideas. Browse the ACA website for information. Or just get yourself a big bowl of popcorn and turn on Netflix. Whatever it is that helps you meet the challenges professional counselors face, I encourage you to do that on a regular basis. I also strongly suggest that you schedule your self-care activity in your calendar.

I know that your ACA Governing Council is committed to serving, helping and advocating for you. The actions taken related to licensure portability, reimbursement issues, practice issues in the age of COVID-19, and anti-racism are just four examples of the myriad topics the board has addressed over the past few years. Another important decision the Governing Council has made is that the 2021 ACA Conference will be virtual. While we will miss out on in-person chats and hugs, I like the idea that even more professional counselors will have the chance to gather, learn, network and even socialize with one another. More information can be found at

I would love to have your suggestions about what ACA can do for you. In asking that question and receiving suggestions, I sometimes find that we are already providing that resource or service, but that it has not been well publicized. Other times, suggestions from members have resulted in our exploring and acting on an issue.

If you have time, I would also like to hear what you do to ensure that you are practicing self-care. You can send me a quick email or photo because I truly am interested. When you share that information, I also think it serves as a good reminder to continue that practice.

As always, I look forward to your comments, questions and thoughts. Feel free to call me at 800-347-6647 ext. 231 or to email me at You can also follow me on Twitter: @Richyep.

Be well.