Monthly Archives: September 2021

Fostering healing and community through an art and wellness magazine

By Russ Curtis, Lisen Roberts and Merry Leigh Dameron September 29, 2021

As a nation, we have faced several grim statistics in the past few years. Suicide rates have increased more than 30% in half of the states in the U.S. since 1999, and the opioid crisis has become an epidemic. In addition, adverse childhood experiences will likely rise because of the increased isolation and lack of school support services during the COVID-19 pandemic. These statistics are further troubling considering that mental health and addiction issues often begin in adolescence and lead to long-term disability, failure to achieve one’s highest potential and premature death.

Thus, it’s paramount to reach young people using multivariate, systemic and effective outreach methods. Using social media and other online venues can be more effective in reaching larger audiences than using simple public awareness messages, and this method is particularly salient during times requiring social distancing. With grant funding from the Jackson County and North Carolina Arts Councils, the Western Carolina University (WCU) counseling program collaborated with local public schools throughout western North Carolina to create an online art and wellness magazine called Masterpeace. We invited K-12 students to submit art for consideration in this publication, which was designed to do the following:

  • Create an engaging online (and print) magazine that celebrates local student art
  • Build university-school partnerships
  • Collaborate with counseling graduate students to provide mental health and wellness education to children, adolescents, parents, teachers and counselors
  • Destigmatize mental health issues
  • Increase conversation among parents, students, faculty and community members about the importance of seeking help for mental health needs

Healing through art

Coupling art with wellness information is particularly advantageous because research indicates that creating and appreciating art is therapeutic. Creating art elicits similar brainwave activity to what is observed in people while meditating. Art therapy is effective in helping clients who have experienced domestic violence, trauma, depression, personality disorders and schizophrenia.

Artists are visionaries who follow their hearts, not crowds, and are regularly at the forefront of societal change. Often it is music, paintings, graffiti or murals that bring much-needed awareness of inequality and oppression to the public. The aim of this art and wellness magazine is to encourage and nurture students’ creative genius to inspire others to instill a more collaborative and just society.

Expanding the reach

An online magazine can be an effective tool because 95% of teens have access to a smartphone, 89% of them are online multiple times every day and 40% say they prefer to receive health information online versus face-to-face medical visits. In addition, accurate online health information decreases anxiety and depression and increases stress management, healthy relationships and academic achievement. Evidence suggests that online health education is particularly salient for stigmatized topics that adolescents would typically avoid in face-to-face settings.

The WCU counseling program tested the efficacy of including art with mental health information on the university’s social media platform. First, we placed suicide prevention information on the counseling program’s Facebook page. Then, the next day we included student art with the same suicide information post. Adding art to the post increased the reach of the suicide prevention message: 46 more views (168 total), 152 more engagement (165) and 11 more likes (17).

Strengthening university, school and agency relationships

Masterpeace magazine enhances our university, agency and school partnerships by providing an engaging way for students, parents, counselors and teachers to interact during a period of social isolation. The teachers have told us how much they appreciate having the online magazine to discuss with their students and inspire them to create art. For instance, a middle school counselor was working with a student who was new to the school and struggling to fit in. He suggested she join the art club, so she did. And one of her artworks was published in Masterpeace. The counselor said it significantly improved her attitude and school engagement. Another art teacher told us that one of her talented high school student’s intermittent depression was visibly improved after their art was published in the magazine, and the teacher also believed that this publication would increase the student’s chances of receiving college scholarships. It may sound cliché but helping even one student thrive is well worth this publication.

Excitement for the magazine was evident from the number of students and schools that participated. There was a 100% increase in the number of students and a 27% increase in the number of schools that contributed art between the 2020 and 2021 editions. To date, the first two issues of Masterpeace have been viewed over 4,700 times, a reach that is significantly more than faculty could have accomplished by speaking to schools and community groups.

We hope that collaborating with community schools and agencies will also increase their involvement in counseling student field placements, service-learning opportunities, internships, practicums and other partnerships.

Another benefit of this project is that it involves counseling graduate students using what they learn in classes about mental health wellness and prevention to provide salient information throughout the magazine. In turn, this project benefits both graduate and K-12 students because it encourages counseling graduate students, who will become future counselors, to apply course material so that K-12 students will understand and use it in their lives.

Honoring the foundation of the counseling profession

We believe this magazine has a broader and more nuanced purpose. The counseling profession was founded on prevention and wellness principles, and it has increasingly been a leader in the behavioral health field on diversity, social justice and equality issues. The beauty and originality of art are emblematic of the counseling profession’s desire to honor the truth and uniqueness of everyone and allow them to express themselves in their own way. Much like the vision and imagination it takes to generate art, we believe this magazine speaks to the ethos of the counseling profession by honoring the varied and meaningful ways we all contribute to the world, creating an ever-evolving and highly complex beautiful tapestry of humanity.


Enjoy flipping through the 2020 issue and the 2021 issue of Masterpeace, and follow us on Instagram @masterpeace.artmag.

“The New King of the Jungle” by Marina Mace, the cover art for the 2021 issue of Masterpeace magazine (published by Western Carolina University in collaboration with the Jackson County and North Carolina Arts Councils)



Russ Curtis is a licensed clinical mental health counselor and a professor of counseling at Western Carolina University. Contact him at

Lisen Roberts is the department head of human services and an associate professor of counseling at Western Carolina University, where she oversees 10 academic programs. She continues to be involved in school counseling, counseling ethics and social justice issues. Contact her at

Merry Leigh Dameron is a licensed school counselor and assistant professor of counseling at Western Carolina University. Her research interests include social justice in education, alternative education and school counselor cultural competence. 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.

Tapping into the benefits of EMDR

By Lindsey Phillips September 27, 2021

Andie Bernard, a licensed professional clinical counselor at Rootworks Wellness in Cincinnati, was working with children and families in marginalized communities who had experienced complex trauma, but she didn’t get the sense she was truly helping them get better through the use of play and talk therapies.

“As I was treating these children and their families, I just couldn’t get to the root of what was really needed to make lasting gains. Their bodies were calm with me in session when they could be, but they were activated everywhere else,” she recalls. “I needed something more powerful beyond talk and play. I needed something that could help to reshape their worldview [and] their belief about themselves.”

This led Bernard to eye movement desensitization and reprocessing (EMDR) therapy. After using the therapy, she finally started seeing improvements with these clients. 

EMDR was developed in the late 1980s when Francine Shapiro discovered a connection between eye movement and a decrease in the negative emotions associated with her own upsetting memories. More than 30 years after EMDR was first introduced, it has not only proved to be effective but has also been recognized by the World Health Organization, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense as a primary treatment for posttraumatic stress disorder (PTSD). 

EMDR pulls directly from many evidence-based therapeutic approaches such as psychoanalysis, cognitive behavior therapy and somatic therapy, notes Bernard, a member of the American Counseling Association. Like psychoanalysis, EMDR therapy explores clients’ past, present and future, but its aim is to help clients realize that what happened to them in the past is not happening now. The cornerstone of EMDR, Bernard explains, is the adaptive information processing model, which asserts that humans will move themselves toward healing once they have all necessary information and can see it adaptively. 

Our body’s ability to naturally heal itself from a cut is similar to how we heal emotionally, Bernard points out. “But if we are unconsciously locked in unsafe experiences that still feel true, the body cannot get to that natural healing,” she says. “EMDR moves the past into the now in partnership with the therapist so the client can see what’s in front of them and assess threat from today.” 

Bernard, an EMDR-certified therapist and a consultant-in-training with the EMDR International Association (EMDRIA), finds that clients often come to counseling with a myopic view of their problems. EMDR therapy helps them widen that lens and move toward healing.

How EMDR differs from other approaches

The first three phases of EMDR (history and treatment planning, preparation and assessment) are similar to other counseling approaches because they focus on understanding the client’s full history, building a strong therapeutic relationship, creating safety, and cultivating coping skills that are centered on the mind and body. Phase 4, desensitization, is where EMDR shifts toward a neurobiological approach by helping the client change the way the brain and body associate the trauma with its trigger, Bernard explains. Rather than directing the client to simply share their narrative verbally (as might be done with trauma-focused cognitive behavior therapy), an EMDR therapist will have the client focus on a targeted traumatic memory while they undergo bilateral stimulation such as eye movements. This process speeds up the client’s ability to integrate the material into an adaptive neural pathway, she says, and removes the emotional charge and associated behaviors in everyday life. 

This hints at one major way that EMDR differs from many traditional counseling approaches: It doesn’t require much talking, at least during the desensitization phase. (See sidebar below for an overview of the eight phases of EMDR therapy.) Addie Brown, a licensed professional counselor (LPC) in Virginia and a licensed marriage and family therapist in California, acknowledges that at first it was challenging for her to resist the urge to reflect and validate her clients’ thoughts and feelings. She had to retrain herself to follow the EMDR protocol and respond only with simple phrases such as “go with that” when a client mentioned a new feeling or memory.  

Brown says this aspect of EMDR can be freeing for clients who prefer not to share details about their traumatic experience. “Some clients like the fact that they don’t have to talk a lot, they don’t have to give a lot of details, because there are things that are so shameful for them that they don’t want to talk about. [Talking about those things] can be more traumatizing. They’re still doing the work [with EMDR] … but they’re not having to tell that story over and over again,” notes Brown, an EMDR-certified therapist with a private practice, Harbor Site Counseling, in Woodbridge, Virginia.

Carla Parola, an LPC in private practice at Seven Centers Counseling in Phoenix, once worked with a client who was hesitant to share his history of being sexually abused as a child. She explained to the client that he didn’t need to disclose many details of his abuse while doing EMDR therapy and that he didn’t have to talk about the abuse until he was ready. If he decided to work on a trauma memory, he had to share only the image that represented the worst part of the traumatic experience as well as the emotions, negative cognition and body sensation associated with the image. For example, the client could select the image of “being alone in the closet,” without having to disclose what happened in the closet or the events leading up to it, says Parola, an EMDRIA-approved consultant and humanitarian assistance program facilitator. This explanation eased the client’s concerns, and he agreed to continue with treatment. 

EMDR’s use of bilateral stimulation can be powerful, but some clients are naturally verbal and are accustomed to sharing more details than are required when using EMDR therapy. Clinicians in EMDR training often tell Bernard that they struggle to help some clients effectively target and reprocess certain traumatic memories because these clients seem to want only to talk about their feelings and feel supported by the clinician. 

But there is room for clients to talk and process when doing EMDR therapy, Bernard says. In her sessions, she stays relationally attuned and listens to the client for the first 10-15 minutes. While connecting with her clients, she looks for themes that relate to their already-targeted negative memories and associated self-beliefs. For example, if a client comes in talking about how she was arguing with her husband because he was busy with work and was distant at home, Bernard may say, “I’m wondering if your feelings with your husband this week relate to not feeling important to your mom when you were growing up. Does that feel like it fits?” If the client agrees, Bernard steers the content back to reprocessing the client’s past targeted memories and belief that she is not important. This allows the client to begin seeing how the self-belief she developed in childhood is shaping her thoughts, feelings and reactions in her current relationships. “This is the power of EMDR. We are not asking clients to cope with their symptoms; we are helping them know how they developed them,” Bernard says. 

Unlike other counseling approaches that help clients make a state change (moving from an anxious state to a calm state, for example), EMDR therapy helps clients make trait changes, Bernard says. As she explains, a state change approaches the problem through the brain’s frontal cortex and helps clients learn coping strategies to deal with their symptoms, whereas a trait change involves looking at what is underneath the state by using historical memories, the nervous system and the limbic part of the brain. Integrating new insights and beliefs through bilateral stimulation creates a trait change that helps clients form more adaptive viewpoints and appropriate responses to difficult triggers. 

Bernard uses an analogy to highlight the difference between state changes and trait changes. Whereas a state change requires clients to change lanes (moving from an anxious road to a calm road), a trait change requires building a new highway in the brain that reshapes how clients view their world and themselves in it. 

“If [clients are] interested only in state change and just want to talk through their symptoms to learn ways to cope … that can be accomplished with phase 2 of EMDR. But if [they] want to clearly believe, see and know that the threat has changed regarding that trigger and make a true trait change,” then that involves the latter phases of the EMDR protocol, she says.

When to use (and not use) EMDR 

G. Michael Russo, a visiting assistant professor of counselor education and addiction program coordinator at Boise State University, specializes in integrating neuroscience into counseling practice. He took part in a meta-analysis led by Richard Balkin and A. Stephen Lenz, consisting of research studies from 1987 to 2018, to determine the overall efficacy of EMDR for reducing symptoms of overarousal. They found that EMDR can be an effective treatment for anxiety and trauma, but the results showed varying levels of efficacy — with some reporting high levels of efficacy and others indicating that it may be better to go with a different intervention. 

“None of the articles that were included in the study utilized neuroscience measures. Sowe are unable to explore claims regarding neurological changes resulting from EMDR,” says Russo, an LPC in Idaho. “Some might even say that neurological changes resulting from the EMDR processes are unfounded. However, what we can say is that there very well could be an alternative explanation for client growth in EMDR sessions that does not relate to the eye movement, tactile or auditory stimulation. It is possible that the relationship itself is the agent of change.” Russo presented the findings from the meta-analysis, which has been accepted for publication in the Journal of Counseling & Development, during ACA’s Virtual Conference Experience this past spring.

The bottom line, Russo says, is that despite the potential effectiveness of EMDR, counselors should remain critical consumers when using it with clients. They should ask themselves: When does EMDR work? When doesn’t it work? Who is represented in the research? Is this the best approach for this client? 

According to the VA, other recent meta-analyses suggest that EMDR produces moderate to strong treatment effects for PTSD symptom reduction, depression symptom reduction and loss of PTSD diagnosis. 

“EMDR is not exclusive to trauma or PTSD. It can be applied across the board,” Brown asserts. “There’s so many experiences we have that leave an emotional impact on us, and that really is why EMDR can be helpful, because it’s addressing the emotional impacts we’ve experienced.” Those impacts might include trauma as well as grief, job loss, eating disorders or relationship issues. If a client is having a strong emotional response to an event, or if a negative feeling or memory lingers and the clients wonders why they still feel this way, then EMDR can be a good approach to use, she says. 

Still, Brown acknowledges that EMDR may not be for everyone, so she assesses when and if she wants to use the therapy with her clients. She also explains the process to clients to determine if they are ready to begin the treatment.

Brown finds three main barriers that might prevent EMDR therapy from working with some clients. First, a client may be too emotionally detached. This often happens when family members or friends encourage a person to seek counseling, but the person doesn’t really believe that they need to be there, she says. 

Second, clients may not be ready to completely release their emotions related to an event. Brown advises counselors to use phase 2 of EMDR therapy to explore any potential barriers that would prevent the client from fully processing their feelings. 

Third, an internal conflict could hinder the client’s progress. If a client is working on an issue that conflicts with their value system, they may have to work on that conflict in a different way before attempting to use EMDR, Brown says. For example, a client may not want to completely reprocess and heal from their grief because they would feel guilty about “letting go” of their pain. 

Brown once worked with a client who sought counseling because she was struggling after the death of her son. When Brown asked about her son, the client started sobbing as if he had died the day before and the loss was still very raw; in fact, it had been 10 years since her son had passed away. After a few sessions of EMDR with Brown, the client had lowered her distress level only modestly, from a 10 (high level of distress) to a 6 (moderate level of distress). Despite still being in a great deal of pain, the client was satisfied with that progress, Brown recalls, because she didn’t want to feel better than that. 

Because EMDR therapists are excited about the potential impact this therapy can have, they may be tempted to use it with every client they encounter, Brown says, but that isn’t an ethical practice. She reminds counselors to stay within their scope of competency. Someone recently came to see Brown because they wanted to use EMDR therapy to help them with obsessive-compulsive disorder (OCD). Even though Brown is trained in EMDR and EMDR is a good intervention for treating OCD, she referred the person to another clinician because Brown did not feel competent working with that particular disorder. 

“Just because you’re trained in a really great intervention that can be used for so many different issues doesn’t mean that you, as a clinician, have to use it for all of those issues if you don’t have the clinical competency to address those issues,” she says.

Case example with complex trauma

Larisa Lomaeva/

Bernard offered to provide a case example (based on a composite of her clients) to illustrate how to apply the EMDR protocol with a client experiencing complex trauma. The client is a woman in her 30s who experienced significant abuse and relational neglect in her family beginning at birth. The client is functional in her everyday life, but she struggles to let go of the shame and feelings of responsibility for what happened to her. “Kids are hardwired to believe that traumatic things that happen to them are their fault, and she was no exception,” Bernard notes. For many years, the client coped with the trauma by dissociating her mind and body from her past experiences. She had gone to counseling on and off throughout her life, but this was largely unsuccessful because she was stuck in the childhood belief loop that her past traumas were her fault.

During phase 1 of EMDR, Bernard gets to know the client and her history. EMDR allows counselors to be creative when taking a full history, she notes. Bernard asks the client to mark on a chronological timeline (from ages 1 to 38) any significant events that have affected her or contributed to her symptoms and how she sees herself today. This includes both positive and negative experiences. Bernard sets a three-minute timer, and the client marks these events in grounded silence. 

When the client finishes, Bernard looks for any marks that are more pronounced than the rest — those with a thicker line or a circle around them, for example. She notices one mark is larger, and she asks the client to tell her about that event. The client says, “This is when I met my one and only true friend.” Bernard writes this down at the top of the timeline. 

Bernard continues to discuss these experiences with the client, marking positive events on the top and negative events on the bottom of the timeline. Clients are often stuck in seeing only the negative, Bernard explains, so marking the timeline in this way helps show clients the duality of their experiences (i.e., some are hard, while others are good or OK). 

Highlighting these positive experiences is also the first step toward building the client’s resources, which occurs during phase 2 of EMDR. This phase is crucial for this client because initial sessions reveal that she has limited resources for assessing her own relational and physical safety, which often leaves her hypervigilant, anxious and overwhelmed in everyday life. 

Bernard asks the client how she feels about the memory of making that one true friend. The client replies that she doesn’t have any feelings about it, which becomes a theme indicating to Bernard that the client is experiencing some levels of disassociation. 

After three months of working on creating a sense of safety, developing a strong therapeutic alliance and cultivating coping skills, Bernard determines that the client still does not have sufficient resources to target distressing memories in the latter phases of EMDR, so she decides to use EMDR to increase access to stabilizing resources with the client. This allows them to tackle the issue through a strengths-based approach by targeting positive (rather than negative) memories and beliefs.

“EMDR is an artful, flexible and powerful approach to meet any client where they are in their healing journey,” Bernard says. “We can use the bilateral stimulation to reprocess past traumas or to help them see their strengths and resilience in the present, in spite of the trauma. So many clinical choices are possible for EMDR clinicians who understand the robustness of the protocol and can apply it creatively to the therapy.”

Next, Bernard writes down a list of positive things the client is responsible for, such as surviving her past abuse, graduating from college, and being a good teacher and parent. She asks the client, “Are you responsible for all this?” Then she uses bilateral stimulation to grow these positive neural pathways in the client’s brain. This allows the client to focus on the present positive experiences instead of the negative feedback loop that stems from her past abuse. 

“While I’m building resources, I’m also teaching past versus present orientation to this client,” Bernard explains, “so, later, when we’re doing the hard traumatic reprocessing, I can say, ‘See those experiences back there? That is over; you made it through.’” This is a powerful aspect of EMDR therapy, she asserts, because it allows the client’s mind and body to begin to know that the past traumas are over and they are safe.

A few months later, the client is ready to target the traumatic memories, including the thoughts, sensations and self-beliefs developed from those experiences. The self-beliefs formed by her early trauma are such foundational elements of her present self-concept that she and Bernard must target them one at a time. After working on reprocessing the memory to understand it (using bilateral stimulation), they integrate the new insight into the body to create new meaning. This process is repeated for every traumatic memory target, which ultimately allows the client to revise the thought that she is responsible for what happened to her as a child. 

After reprocessing the traumatic memories for several months, the client no longer feels responsible for the past abuse that happened to her. The client now sees her abusers as a row of dominoes and realizes that she no longer belongs in the same line with them.  

“This shift could not have been achieved without the use of EMDR’s full protocol of using bilateral stimulation in conjunction with holding the traumatic memories, images and bodily sensations; processing the emotions; and redefining what the experience has come to mean to [the client] from a vantage point of safety and recognition that it is in the past,” Bernard notes.

Now, the client possesses a healthier sense of self and stronger boundaries, works in a career she loves, and feels safe in her own mind and body again. 

Be fluid, not rigid

As an EMDR coach, Bernard has seen several competent therapists doubt themselves when undergoing EMDR training, which involves five intense days of learning new terms and concepts. She recently wrote a blog post, “Five things every newly trained EMDR therapist wished they knew,” to address these issues. In it, she reminds practitioners that they don’t have to be competent when starting out. Instead, she recommends that they remain curious and practice with other EMDR-trained therapists in consultation to grow their confidence. 

“EMDR is a protocol and a process to learn, but it’s an art when delivered,” Bernard says. If counselors are too rigid or more cognitive-oriented, then they may struggle with EMDR, she notes, and they may not be able to create a sense of coregulation with the client. 

“The protocol feels linear, but it’s not always the case,” Bernard emphasizes. Counselors should move through the EMDR phases as needed in attunement with their clients. If they try to stay too on script or are overly focused on what phase they are in, then the approach will feel rigid and affect the energy in the room, she points out. In addition, they may not be attuned to what the client just said or what the client needs. 

Most counselors are well-intentioned and want to get it “right,” Bernard acknowledges, which is why having colleagues and consultants to support them while learning and remind them to trust their clinical instinct is so important. She always advises her trainees to practice EMDR with fluidity rather than rigidity. 

Counselors can be faithful “and have efficacy to the treatment model while also being creative and flexible,” she says. “In the beginning as a new EMDR therapist, is it going to go slower? Yes. Is it going to be more impactful and profound and life-changing for you and the client than many other clinical approaches? Yes.”

Don’t rush the process 

People often assume that phase 4 — the desensitization or bilateral stimulation component — is EMDR, but that is wrong, Bernard says. If counselors jump too quickly to desensitization, then clients can get overactivated. “When we take people to intense feeling states without paying close attention to their window of tolerance, they can’t stay present in their body, and if they can’t stay in their body, we’re not healing them. We’re retriggering them,” she explains. 

She advises counselors to slow down and not to overlook or rush phase 2. This phase helps prepare clients to handle the intense emotions that may come up during latter phases of EMDR by using containment skills such as a mind-body shift, deep breathing, safety cueing, mindfulness and grounding. 

“When working with clients with complex trauma or highly activated ones with anxiety, depression or dissociation, you’re going to spend important time creating safety, strengthening the therapeutic alliance and building regulation skills to use to bring them affectively down when in later reprocessing phases of EMDR,” Bernard says. 

She assesses a client’s sense of safety the moment they walk into her office, asking them what makes them feel safe about the room. If a client responds by saying, “I know where the front door is,” then she knows their sense of safety is low and that she will need to strengthen it to prepare them for EMDR. If, on the other hand, the client responds, “I like the colors in your office and your plants,” then she knows the client possesses a higher degree of safety to leverage during the reprocessing phases.  

Parola has found some clients are hesitant to proceed with EMDR therapy because they worry the dual-attention stimuli (or bilateral stimulation) involves hypnosis or that they will not be in control of their emotions or body. So, she introduces them to the concept of dual-attention stimuli by doing a slower and shorter version of it when they are establishing the client’s safe place in phase 2. The client picks a place that makes them feel safe. Then she tells them to think about an image that represents this place and asks, “What emotions are you feeling? What sensations are you having?” If the client is having a positive reaction, she incorporates short, slow dual-attention stimuli to reinforce this resource. This helps the client prepare to use a faster and longer version of dual-attention stimuli later when they are reprocessing memories that are more traumatic, she says. 

Brown notes that some clients say they are ready to begin processing their traumatic memories but then hit an emotional wall during the latter phases. For example, someone who was constantly told by their parents as a child not to cry may protect themselves by learning how to stop themselves from crying. If they don’t address this barrier before moving to the desensitization phase, then this protective strategy may prevent them from fully feeling that emotion during treatment, Brown explains. For that reason, she started incorporating the internal family systems model (which views the mind as made up of subpersonalities or “parts,” each with its own unique viewpoint) during phase 2 of EMDR to ensure that, together, they explore all parts of the client and address any barriers that could interfere with healing. 

“Phase 2 is life-changing but is often overlooked by many EMDR therapists,” Bernard stresses. “If we have limited time with a client for reasons outside of our control and are only able to help them develop accessible feelings of safety and much-needed cognitive and somatic regulation resources, we have still changed their lives in powerful ways, even without the trauma reprocessing.” 

Adapting to the client’s needs  

EMDR therapy continues to evolve and now has specialized approaches that address the needs of certain populations or mental health issues. For example, the desensitizing triggers and urge reprocessing (DeTUR) protocol was developed by AJ Popky to treat addiction; this approach helps clients target their desire to use drugs or alcohol while also addressing underlying traumas. 

Parola, who is EMDR sand tray certified, sometimes incorporates sand tray techniques throughout the eight phases of EMDR therapy. For example, she may have a child use the figurines in the sand tray to represent a safe place while she engages the child in bilateral stimulation by slowly moving a paintbrush back and forth across the child’s hand. 

Counselors can also make modifications to the eight-phase protocol. Bernard’s case example illustrates one adaption of tailoring the protocol toward installing resourcing and adaptive self-beliefs, rather than processing trauma, because the client’s internal resources were so low initially. 

Bilateral stimulation is another way counselors can adjust the protocol to fit clients’ individual needs. Eye movements are the most commonly used and well-researched form of bilateral stimulation, but clinicians can also use tapping, tactile stimulation or auditory tones. Bernard finds using tappers for bilateral stimulation helpful for people with attention-deficit/hyperactivity disorder or who are highly distractable because it allows them to close their eyes and tune in to their body. For clients who dissociate or those who have difficulty managing their emotions, she often uses a light bar (a bar containing LED lights that move back and forth) or finger movements because the proximity allows her to notice changes in clients’ eyes as they track the movement. 

Brown discovered that several of her clients didn’t want to use the light bar for bilateral stimulation and didn’t want her sitting in front of them during the reprocessing phases. So, she adjusted to better meet their needs. She often sits off to the side where she can still observe them from a safe distance, and she allows clients to use different types of bilateral stimulation. Most of her clients prefer holding pulsers that vibrate, but she has one client who chooses to simply tap on the side of their leg. 

Research continues to shed new light on ways EMDR can be used to help clients who are struggling with trauma and other mental health issues. Two recent articles in EMDRIA’s Go With That magazine discuss how EMDR can be used to address racialized trauma and addiction.

Bernard notes there is promising research highlighting that just taxing working memory (and not necessarily with bilateral stimulation) shows signs of decreasing the emotional charge around traumatic memories. 

Bernard appreciates that Shapiro’s theory has given her an eight-phase protocol that allows her to be with her clients in extraordinarily profound ways: “Any therapy that sees the person as a whole — brain, body and mind — that asserts it’s not about what’s wrong with you but what happened to you, that teaches what happened to you then is over and we’re here now, and that says the information your body is sending to you is an important part of your own healing … is a gift to the therapeutic community at large.”


1) History and treatment planning (discuss the client’s history, develop a treatment plan, assess the client’s internal and external resources)

2) Preparation (build a therapeutic alliance, explain EMDR, set expectations, build the client’s coping strategies)

3) Assessment (identify the event to reprocess, establish a baseline with the Subjective Units of Distress (SUD) and Validity of Cognition measures)

4) Desensitization (use bilateral stimulation while the client thinks about the traumatic event with the goal of reducing the client’s SUD to zero)

5) Installation (strengthen a positive belief that the client wants to associate with the target experience until it feels completely true)

6) Body scan (ask the client to think about the target event and positive belief while scanning the body from head to toe, process any lingering disturbances with bilateral stimulation)

7) Closure (help the client return to a calm state)

8) Reevaluation (discuss recently processed memories at the beginning of a new session to ensure the client’s distress is still low and positive cognition is strong, determine future targets and directions for continued treatment)

(Information adapted from EMDRIA)



Lindsey Phillips is the senior editor for Counseling Today. 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.

Voice of Experience: Three pieces of anger

By Gregory K. Moffatt September 23, 2021

He was court mandated, and to stay out of jail, he was required to engage in several months of anger management counseling, among other things. I was his choice as a counselor.

An incident of road rage had resulted in this outcome. The other driver had recklessly cut my client off on the interstate. His temper flared, and he pursued the other driver, eventually bumping her car and nearly causing an accident. The other driver was a young mother on her way to work with two children in car seats in the rear of the van. She called the police, who pulled my client over and arrested him.

My client didn’t have a single mark on his police record prior to this incident and said he had never done anything else like it in his 38 years of life. In our early sessions together, he was as befuddled by his behavior as the frightened young mother must have been on the highway.


Anger is a fascinating emotion. It is completely visceral. You can’t “decide” to be angry any more than you can decide to fall in love with someone. Instead, in a way, anger attacks us out of the blue, as it had done to my client.

People express anger differently depending on a variety of factors, including personality, coping skills, history and context. Regardless, we are all its victims at one time or another, and sometimes this emotion deceives us. In fact, anger can be much “safer” for us to express than other emotions. A counselor once told me that depression is really hidden anger, and while that may often be true, I believe the opposite is also true. It is sometimes easier to be self-righteous and angry than it is to admit that your heart is hurting.

I’ve had clients who have threatened others with weapons, engaged in violent road rage, and even some who have killed their workmates. Very few of these people planned their behaviors ahead of time. They acted spontaneously in the heat of passion (pardon the cliché).

I have witnessed anger many times in my clients, and I’ve recognized some things that help me manage it. Early in my career, “anger management” involved a set of techniques such as deep breathing and the development of varied coping skills. While those are certainly important areas on which to focus, I was missing a piece of the puzzle at the time that is also critical in managing anger.

Anger has three common components or pieces, and if we help our clients address these three issues, they will have new tools for coping in a variety of situations.

The first component is loss of control. When all of our tools for coping are expended, we are reduced to primitive behaviors. Think about how illogical (yet common) it is to push an elevator button repeatedly. In the midst of our frustration, we push the button again and again, even though we know it won’t help. This is where the use of deep breathing (or another relaxation technique) is very helpful.

My client had been feeling a loss of control at work and a loss of control at home. When the other driver’s behavior caused him to feel a similar loss of control that day in heavy traffic, he tried to retake control by “punishing” her for her reckless driving.

A second component of anger is that the precipitating event is perceived as personal. My client perceived that the other driver was doing something deliberately to him (as if she had planned specifically to make him angry) when, in fact, she was simply in a hurry and wasn’t thinking. The irony in road rage is that we depersonalize the other driver and at the same time perceive their behavior to be a personal and intentional attack on us.

Finally, the third component is a belief that one has been wronged — that life isn’t fair. My client believed that “other drivers shouldn’t be so careless.” In a way, he was trying to make the world fair by righting a wrong. That thinking is quite illogical but very common in road rage incidents.

The rage my client experienced had occurred partially because his defenses were down. He had just wrapped up a very bad day at work, his home life was at a low point, and in the safety of his car — his own domain — he let his normal coping skills fly out the window.

After weeks of counseling work, my client went on about his life a much healthier person. By looking at these three pieces of anger, he was able to learn to recognize cues and apply anger management techniques. I hope he’ll never see the back seat of a police car again.



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


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.

Assessment, diagnosis and treatment planning: A map for the journey ahead

By Bethany Bray September 22, 2021

Clients impart so much about themselves, verbally and nonverbally, in counseling sessions that it will overwhelm clinicians who don’t organize the information and use it to create a structured plan for their work together, contends Nathaniel N. Ivers, associate professor and chair of the Department of Counseling at Wake Forest University.

Fully understanding a client’s situation, symptoms and needs and then matching them with a diagnosis (when appropriate) and a treatment plan that will help them heal, grow and thrive are core aspects of professional counseling. Counselors learn these skills, at least conceptually, in graduate school but gain true understanding of them through their direct work with clients. 

Practically applying that knowledge is “where the rubber hits the road,” says Ivers, a member of the American Counseling Association. Examining a client’s concerns in depth — moving beyond surface-level questions such as “How did this week go?” or “What do you want to talk about?” — is the most integrative and effective way to devise a rich treatment plan and pinpoint a destination that the client and practitioner will work toward together in therapy.

Ivers acknowledges that counselors who are busy with full caseloads may be resistant to the idea of dedicating time to create a comprehensive, integrative plan for each client. But as he tells his students: The more you do it, the easier it will get.

“Eventually, you won’t have to write out a full, multipoint case conceptualization plan for every client,” says Ivers, a licensed professional counselor in Texas and a licensed clinical mental health counselor in North Carolina. “But when you eventually have … trouble figuring out [a case], that’s when you need to fall back on it — put pen to paper and conceptualize a full plan.”

When teaching these concepts to students, Ivers often shares a quote from psychologist Donald Meichenbaum, professor emeritus at the University of Waterloo in Canada and one of the founders of cognitive behavior therapy: “A clinician without a case conceptional model is like a captain of a ship without a rudder, aimlessly floating about with little or no direction.”

An important responsibility

The three components of assessment, diagnosis and treatment planning are intrinsically linked and provide a “map” for counselors to offer evidence-based treatment that best fits the client, says Shannon Karl, an ACA member who is a professor and field-based clinical coordinator in the Department of Counseling at Nova Southeastern University in Florida. Not only is the process vital to establishing a foundation for counseling work with a client, but it also creates a pathway for the individual to access appropriate treatment services from counselors and interdisciplinary professionals.

Assessment, diagnosis and treatment planning are important responsibilities, and mastery of these skills is often closely tied to clinician confidence, Karl says, so it’s understandable that new professionals may worry if they are getting things right. She urges counselors who feel this way to remember that their mentors are there to advise and support them. Similarly, counselor education and supervision programs are meant to help trainees through this learning curve, she says.

Even so, both novice and experienced counselors should seek continuing education, peer consultation and mentorship in these areas throughout their careers, stresses Karl, co-author of the ACA-published book DSM-5 Learning Companion for Counselors. It is imperative for counselors to keep these skills sharp and up to date, not only because they are integral parts of the counseling process but also because diagnoses and related criteria are constantly changing and evolving.

Karl was on an ACA task force formed to study the updates and changes introduced in the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) in 2013. She was dismayed, she says, to see how long it took many counseling practices to update their procedures to reflect the changes made between the fourth and fifth editions of the DSM.

Karl urges clinicians to stay informed and up to date by attending workshops, conferences and other continuing education events; consulting regularly with professional peers; seeking mentorship or supervision; joining professional Listservs; and reading counseling journals and other publications. Remaining active with state and local counseling organizations will also help practitioners stay abreast of criteria and processes that vary state to state, she notes. Leadership within the counseling profession must ensure that funding for continuing education on assessment, diagnosis and treatment planning is prioritized, especially for counselors in economically disadvantaged or rural areas and settings where practices or clinics are short-staffed, Karl adds.

“One thing we can do at all levels is make sure that clinicians have access to free or reduced-cost continuing education, workshops and seminars. Accessibility is important,” says Karl, a licensed mental health counselor whose area of focus is childhood trauma and DSM-5 disorders. “It’s important for professional counselors, regardless of work setting, to be able to best serve their clients, and one way to do that is to be active in learning regarding assessment, diagnosis and best treatment planning. We can’t help others heal in isolation.”

Danica Hays, author of the ACA-published book Assessment in Counseling: Procedures and Practices, notes that counseling graduate students often take only one class each on assessment and diagnosis. Continuing education, in addition to competency gained through experience, is needed to round out counselors’ knowledge, she says.

“With the amount of material to cover, [counselor graduate education] lessons are often distilled to case conceptualization and treatment planning as simply following a recipe,” says Hays, a professor and dean of the College of Education at the University of Nevada, Las Vegas. Gaining comprehensive knowledge that includes “other ways of knowing — often from scholars and practitioners of color — can be incredibly helpful to ensure clients are not harmed by an incomplete and/or distorted story told on their behalf,” she adds.

Client driven

Tracie Keller, a licensed professional clinical counselor and supervisor in Ohio, has found that teaming directly with the client to identify goals and build a treatment plan strengthens the level of trust and rapport between clinician and client, which in turn improves treatment outcomes. She chooses to highlight this collaborative approach on the website for her group practice in Columbus, Ohio, by including the following statement: “We believe that treatment planning is a process that both the therapist and the client determine together.” 

Keller tries to think about the process from the client’s perspective. She notes that if she went to a medical doctor and the doctor prescribed a treatment plan and medication without bothering to tell her that she had the flu, she’d question what was going on and whether the doctor valued her input.

Keller, who specializes in treating clients with eating disorders and trauma-related concerns, says a prescriptive approach has never really worked for her. “[Clients know] themselves the best,” she says. “For me, it [collaborative treatment planning] is something that helps build a lot of trust. It’s not just prescribing ‘this is what I want you to do,’ but instead walking alongside [clients] to execute the goals they want. … If the client doesn’t buy in, [counseling] won’t be successful.”

Hays notes that involving clients in case conceptualization and treatment planning also allows for better cultural understanding and responsiveness. Counselors have a significant responsibility to get a client’s story right, she says, and “getting the story right involves co-constructing it with the client in a way that honors their cultural experiences as well as points of trauma and resilience.”

“Really good assessment is committing to gather a client’s story with that client, engaging in basic helping skills to affirm what the client is sharing as they share it, incorporating multiple qualitative and quantitative tools in the process, and proposing and evaluating treatment approaches with the client,” Hays asserts. “Thus, assessment may not involve many questions but [rather] more space within sessions for the client to share their stories, with the power and voice to confirm or disconfirm an evolving conceptualization of those stories.”

When Keller begins working with a new client, she listens carefully as they talk through their history and symptoms. Possible diagnoses and issues to work on in counseling often become apparent to Keller as she listens, but she stores those ideas away for the time being. Instead, she prompts the client to think of treatment goals, asking questions such as “If you could change anything in your life through our work together, what would that be?” or “What would you want to be different in your life after our relationship concludes?”

Clients presenting with symptoms of an eating disorder might respond with statements such as “I don’t want to fight my body anymore” or “I’m sick of hating my body,” Keller says. In this example, Keller and the client might work together to create a goal of improving the client’s body image in counseling. Later, once the client has made some progress on that goal and established a stronger therapeutic relationship with Keller, she will circle back to some of the issues that revealed themselves in the initial assessment session and try to tie those issues into the client’s treatment goals. If the client mentioned purging behavior or restrictive eating in the initial session, for example, Keller might gently raise the idea that this behavior could be something to work on as part of reaching the client’s goal of obtaining a healthy body image.

Because Keller accepts insurance at her practice, she diagnoses all of her clients to submit for reimbursement. Keller lets each client know that she will share their diagnosis with their insurance company, and she dedicates time to explaining the diagnosis to the client and how she arrived at that decision. Depending on the client, she sometimes takes out her copy of the DSM-5 in session and looks through the diagnosis criteria with them.

“I talk about it from the start because they’re in a very vulnerable space [at intake], and it’s important to be really transparent about what their diagnosis is and what it means,” Keller says. She never moves forward with a treatment plan or diagnosis unless a client agrees to it.

After talking through the diagnosis with the client, she explains the methods and tools she uses (such as cognitive behavior therapy or eye movement desensitization and reprocessing) to treat that particular diagnosis and how she will tailor her approach to help the client meet the treatment goals they have identified.

A large portion of the initial goal-setting and therapeutic work with clients is frequently focused on reducing symptoms, Keller notes. As treatment progresses, she works with clients to shift or change treatment goals to move beyond symptom management and to focus on the issues that lie beneath their original presenting concern.

For example, a client with chronic depression might first identify goals that involve improving their mood and alleviating their symptoms. Later, as their symptoms lessen and the client is feeling better, they could be ready to focus on past trauma or relationship issues that they didn’t have the bandwidth to tackle earlier, Keller says. 

She finds this process often happens organically; the “win” of seeing symptoms lessen often motivates clients to identify additional goals. “It’s cool because you have a lot of trust and past success in therapy [at that point] to go off of, and the client often wants to dig deeper and make greater changes,” Keller says.

Client treatment plans need to evolve and stay flexible because clients’ needs will change throughout therapy. Keller notes that it is common for individuals with eating disorders to experience periods when their symptoms worsen, sometimes to the point of needing hospitalization or inpatient care. Whenever this happens, Keller works with the client to shift their treatment plan and identify different goals for the near future, and then they repeat the process after the client has been discharged or their situation has otherwise improved.

Assessment shouldn’t be limited to the initial and concluding sessions with a client. As Keller points out, an important part of this process is being attuned to a client’s needs and blending assessment work into each session. She says that she continually listens for short- and long-term treatment goals.

“As you go on through treatment, you’re getting information [from the client] with each session,” Keller says. “As you walk with them, you’re learning more and more: how they relate to you, how they relate to other people. You can’t ignore that information. It will guide you. I’m constantly assessing and holding that information.”

Keller acknowledges that her understanding of the treatment planning process has expanded over time. “Now it’s a process that is pulled up in my mind during every single session — not just at intake and conclusion,” she says. “Even if I don’t verbalize it with the client, I’m thinking of every conversation through the lens of their goals. It becomes an unspoken but ever-so-present aspect of the work, and it moves it along.”

Diagnosis: A love-hate relationship

Many professional counselors have mixed feelings about diagnosis. On one hand, it can be a tool that connects clients with the mental health care they need. On the other hand, it can be viewed (both by clinicians and clients) as a “label” that follows clients throughout treatment and, in some cases, life.

Keller says she understands both sides; however, she values diagnosis and finds it useful. Diagnosis is a tool that allows her to understand how she can initially help her clients, and it guides her interventions and therapeutic approach as treatment progresses. It can also remove financial barriers to mental health care. Counseling can be expensive, and insurance companies typically require a diagnosis for reimbursement. So, Keller views diagnosis as a way of providing treatment access for clients who wouldn’t be able to afford counseling without insurance coverage. 

The key, Keller says, is to be fully transparent with clients and include them in the diagnostic process, especially for diagnoses that can carry a stigma, such as personality disorders, substance use disorders and eating disorders. In some cases, counselors may need to offer psychoeducation to dispel inaccuracies or stereotypes about a diagnosis.

“I can have a love-hate relationship with it [diagnosis] at times,” Keller admits. “It can have a stigma and the burden of sharing it with insurance. … Oftentimes in therapy, we end up having to process and unpack a lot, [including] what they [clients] have heard and experienced in carrying that diagnosis. If I can be involved in that process with them and acknowledge the stigma, I can help them.”

Ivers says there can be limits to diagnosis, including when clients develop a sense of dependency on their diagnosis or use it as a “crutch.” But as a whole, he finds that the process of diagnosis generally encourages counselors to seek out best practices, research and resources to help and support their clients.

“We have to be cautious that we don’t reduce people to their diagnosis,” Ivers warns. “But for others, finally receiving a name for the cluster of symptoms they’re experiencing can be a relief. It also can open them up to treatment and connect them with you [their counselor] or other practitioners who can help for their specific concern, [including] prescribing medication.”

Karl agrees that one benefit of diagnosis is that it often helps connect clients to interdisciplinary treatment. Even if a counselor is not required to assign diagnoses to clients, they need to have a “comfortable awareness” and foundational knowledge of the diagnosis process and be able to triage clients to connect them to further treatment if needed, Karl says. Screening skills and competency regarding diagnosis are also a requirement for counselor licensure in many states and therefore something to keep oneself updated on through continuing education, she adds.

Diagnosis also requires counselors to know how to use the DSM. Karl advises clinicians to become comfortable with looking things up in the manual and knowing where to turn when they have questions or need more information, rather than trying to memorize its contents.

Additionally, there are certain conditions mentioned in the DSM that counselors would not be involved in diagnosing, such as neurodevelopmental disorders. Because counselors will often be included in treatment plans for clients with those types of diagnoses, however, they still need to be proficient enough to have an understanding of any DSM diagnosis and its best treatment practices, even if they do not diagnose the client themselves, Karl notes.

Trying to remember all the nuances of the diagnoses in the DSM is “setting yourself up for failure,” Karl says. The DSM-5 contains more than 1,000 pages and hundreds of diagnoses. Even if clinicians were able to remember everything the manual contains, revisions and updates are made to the information regularly. For that reason, Karl urges counselors to focus on having a core knowledge of the manual, being comfortable enough to use it as a resource and adapting with it as it changes.  

Potential bias

Counselors are human beings with individual personalities and worldviews, so there is always a chance of potential bias creeping into assessment, diagnosis and treatment planning. To avoid this, clinicians must diligently reflect on their biases and really think about their assessment questions and diagnosis processes, says Ivers, who presented the session “Using Case Conceptualization to Navigate the Turbulent Waters of the Human Condition” at ACA’s 2018 Conference & Expo.

Ivers stresses that counselors need to critically examine why they are asking what they are asking — and what they are not asking. “If a client is acknowledging some of the cultural struggles they’re facing and we skirt those issues and do not focus on them,” he says, “what we’re telling them is that it’s not therapeutically important.”

“Case conceptualization is a tool, and when used effectively, it can be extremely helpful,” Ivers notes. “But when used ineffectively, it can be hurtful and damaging. In the case of culture, it can actively discriminate and misalign. It can [cause a clinician to] try and fit a client into a mold.”

Clinicians must also keep in mind that assessment and diagnostic tools can have an innate bias. Models often have a “cultural flavor” and are based on what is traditional (or Westernized) rather than on what is deviant or nondominant, Ivers says. He teaches Jon and Len Sperry’s case conceptualization method to his students at Wake Forest. One of the benefits of the model, Ivers says, is that it allows for flexibility and modification based on a client’s cultural factors. (For more information, read Jon and Len Sperry’s Counseling Today article “Case conceptualization: Key to highly effective counseling.”)

“There are evidenced differences in how symptoms are expressed culture to culture and, thus, individuals do not neatly fit in diagnostic or treatment ‘boxes.’ Fostering one’s competency is embracing these tensions,” says Hays, who is an ACA fellow.

She points out that research shows there are disproportionate rates of mental health issues among people of marginalized statuses. “The question has been whether differences in diagnostic rates — based in case conceptualization — are actual differences among cultural groups or whether they are a result of faulty assessment and diagnostic processes on the part of the counselor,” Hays says. “The answer is likely a little of both. Counselor cultural bias does substantially shape assessment and treatment, and experiences of privilege, oppression, trauma and resilience shape what symptoms are presented.”

Keller acknowledges that the potential for practitioner bias in assessment, diagnosis and treatment planning is one of the messiest aspects of professional counseling. What she finds invaluable in this realm is seeking feedback through regular consultation with professional peers as well as attending counseling herself. 

Personal counseling and professional consultation allow Keller to process things, identify her “blind spots” and work through her own biases, “so they don’t come out in the counseling room,” she says. “The last thing I want is for my stuff to affect [my client’s] stuff.”

Ivers admits it is “inherently reductionistic” to take all the information that a counselor gleans from a client through the therapeutic relationship and organize it into a treatment model and plan. There is no way to keep from losing data as the counselor processes all the information, he says.

“Therefore, it’s important to remain flexible and be aware that there can be blind spots,” Ivers advises. “You’re never going to get it 100 percent right, and that’s why we [counselors] are always reassessing and modifying a treatment plan. But you’re hopefully on the right path.”

A career-long learning curve

It’s not easy to competently assess what a client needs and then match those needs with an accurate and responsive treatment plan that will help the person to heal. Therefore, counselors find themselves continually developing and strengthening these skills over the entire course of their careers. 

Keller says it remains her goal to grow her skills in assessment, diagnosis and treatment planning over the decades to come with the mission of better serving her clients. “To be an effective counselor is to trust and to be OK with always learning and pushing ourselves to grow,” Keller says. “If I stop doing that, I probably shouldn’t be practicing anymore. Counseling is a process that I have to be willing to grow and change and evolve with — just as clients do. [Counselors should] trust that wherever you’re at in your professional journey, it’s OK — and it’s good even — to be learning.”



Wrestling with a client’s previous diagnosis

It’s not uncommon for counselors to see clients who have received a prior diagnosis from another clinician. If the client comes via referral, the counselor may have case notes that include the diagnosis in writing. In other situations, a client might report to the counselor that they were told they have a certain diagnosis. This introduces the possibility that the client might have misunderstood or misremembered clinical terms that they heard from the other practitioner or found on the internet.

So, what happens if the counselor, after getting to know the client, disagrees with the previous diagnosis? It’s a common scenario, says Shannon Karl, a licensed mental health counselor and professor at Nova Southeastern University. She urges counselors to remember that individuals grow and change, so a diagnosis shouldn’t stay static. A previous diagnosis may no longer be relevant or applicable for a client, especially if it’s more than a few years old.

Counselors need to come to their own conclusions about a client without allowing a previous diagnosis to color their assessment, Karl says.

Danica Hays, a professor and dean of the College of Education at the University of Nevada, Las Vegas, suggests that practitioners ask the client questions to get additional information about a past diagnosis, including how (and by whom) it was made, how the client feels about the diagnosis, the extent to which the client still identifies with the diagnosis, and how or if they feel that the diagnosis led to finding support to address their symptoms.

“Given the inevitable role of bias in clinical decision-making, counselors should always be cautious when a client presents a treatment history in which they were diagnosed a particular way,” Hays says. “It is important that counselors not quickly jump to a diagnosis based on what has been diagnosed before. This is a clear example of the improper ways that cognitive tools are used to yield misdiagnosis and client maltreatment.”

A counselor’s role also includes ensuring that a client feels heard and trusted when they talk about previous diagnoses or conditions that they think they have but that have yet to be diagnosed, adds Tracie Keller, a licensed professional clinical counselor.

“I try and hold that [information] with respect and honor, but at the same time, I do my own assessment and treatment plan based on what I’m hearing,” says Keller, who owns a counseling practice in Columbus, Ohio. “I use that as a jumping-off point to garner further questions, [as] a starting point to dig deeper.”

Karl once worked as a mental health counselor in a pain clinic where she had the freedom to have an initial session with clients before she opened and reviewed the individual’s records. “Clients really valued that I wanted to take a few minutes to hear it [their mental health history] from them,” Karl says. “They knew they had the chance to share their story with me without any filters.”

Karl acknowledges that this will not be possible for most counselors. However, she urges clinicians to find ways to hear a client’s backstory in their own words, even if they know the client’s diagnosis and case history before the person walks in the door.

“We need to preserve the ability to hear clients’ stories from them,” Karl says. “Keep in mind that we are not defined by our diagnoses; we grow and evolve in positive directions. What was happening previously doesn’t mean it’s happening now. Be aware that assessment is a continual, ongoing process, and a diagnosis is never set in stone. If we come from that lens, it helps us see clients for who they are as opposed to what they’re tagged with.”



Bethany Bray is a senior writer and social media coordinator for Counseling Today. 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.

African Americans and the reluctance to seek treatment

By Patricia Bethea Whitfield September 16, 2021

Amid talks of how African Americans have been disproportionately impacted by the COVID-19 pandemic and speculations about their hesitance to be vaccinated, the Tuskegee experiment has been cited numerous times as a kind of landmark explanation of why African Americans are reluctant to seek treatment. In the Tuskegee experiment, African American men were recruited for what they thought was a medical treatment but was actually a study of untreated syphilis that continued long after penicillin was a recognized intervention for the disease. In fact, the men were never treated, and many went on to infect their partners as well. As unethical as this research is now recognized to be, the reluctance of African Americans to trust systems and seek treatment is actually rooted closer to home, in the long history of mental health abuse and failed mental health intervention for African Americans. 

Today, African Americans face numerous challenges that affect their mental health, including high rates of unemployment, poverty and incarceration; health disparities and disability; the emotional and psychological impact of the pandemic; and the steady uptick of police shootings in the African American community. All of these challenges are complicated by the intergenerational trauma of slavery, the very mention of which often arouses an almost visceral reaction even 150-plus years after it ended. In fact, Africans were brought to this country as slave labor and, along the way, laws were passed to ensure that they and their descendants would continue to be enslaved forever. Over time, the color of their skin was equated with servitude and privation in a way that has persisted for over 400 years. Slavery is our common history, and if it is a shame, it is our common shame. 

Now there are new mental health challenges in the emerging myths that discount the history of African Americans and slavery. The first myth is that slavery is a hoax, meaning that Blacks were never enslaved in this country. The second myth is that Blacks were enslaved but slavery was really not that bad. In the first myth, the discounting of history is insidious. It is meant to befuddle and confound in the same kind of gaslighting experienced by the lead character in the movie of the same name (Gaslight). In this case, the myth is intended to create doubt of perception and historical memory such that Black people are being told, “You think you went through hell, but it did not happen.” In an era of turbulent racial tension, the second myth of slavery as a harmless social good conveys a tone of slavery reconsidered for African Americans, and recent voter restriction laws help to flesh out the second boogeyman as a political reality. This historical revisionism retraumatizes, angers and reactivates centuries-old intergenerational fight-or-flight strategies for coping, including confrontation (rallies and marches) and withdrawal. 

According to the Centers for Disease Control and Prevention (2017), non-Hispanic Blacks are more likely than non-Hispanic whites to report feelings of “sadness, hopelessness, worthlessness, or that everything is an effort all or most of the time.” The U.S. Department of Health and Human Services (HHS) Office of Minority Health reported that suicide was the second-leading cause of death among African Americans ages 15 to 24 in 2019, and the death rate from suicide for African American men was four times that of African American women. African Americans have one of the highest rates of poverty in the United States, and according to the HHS Office of Minority Health, African Americans living below the poverty line are twice as likely as other individuals to report psychological distress. In 2019, the Substance Abuse and Mental Health Services Administration reported that among adults who experienced mental health issues in the past year, non-Hispanic Blacks were significantly less likely to receive mental health treatment than non-Hispanic whites (8.7% compared with 18.6%). 

Despite the evident need for mental health counseling, many African Americans are reluctant to seek treatment. Some of this reluctance may be rooted in the reality that, historically, African Americans have had their mental health abused and their mental health treatment administered with a liberal dose of discrimination and bias. Initially, it was assumed that African Americans could not be mentally ill. The general notion was that a person had to own property and actively engage in business and civic affairs to experience mental illness, and because African American slaves “had nothing and nothing to worry about,” they could not be mentally ill. In fact, when both the 1840 and 1850 U.S. census found such low rates of mental illness among slaves, it was concluded that slavery actually protected slaves from the known diagnoses of the time. 

Science rushed to support pro-slavery views. Physicians and scientists promoted the notion that slavery was such a good thing that a slave would have to be mentally ill to want to leave it. Thus, drapetomania emerged as the first race-based diagnosis. Samuel Cartwright, a physician, coined the term in 1851 to describe a “disease” that made slaves develop an irrational urge to run away from slavery. He also identified a second physical and mental abnormality, dysaethesia aethiopica, thought to attack Black people who had too much freedom. This condition was purported to make them sabotage their work, break things and become confrontational with others. 

While early attempts to label African American behavior seem antiquated and almost laughable today, they have had a profound impact on the regulation of Black behavior and the transmission of intergenerational bias. Over time, resistance to oppression and free labor stereotyped African Americans as “lazy” people who did not want to work, and for their most vociferous resistance to slavery, they were often labeled “deranged.” In this way, race and control were conflated with mental illness in the lives of Black people, and that was just the beginning. Slavery in the United States ended in the mid-1860s, and the usefulness of Blacks for free labor and reproduction of more slaves ended with it. Slavery left a lot of broken families who were never able to reconnect. Employment was nearly nonexistent, and Jim Crow laws codified new subservient behaviors for Black people, who had to go to the back door for service and step off the sidewalk to let white people pass. From 1882-1968, 3,446 Black people were lynched in a campaign of terror, according to Tuskegee Institute. 

Also in the late 1800s, Francis Galton coined the term “eugenics,” the notion that only certain people should be able to reproduce. Herbert Spencer supported this idea with his now famous “survival of the fittest” theory or social Darwinism. Eventually, the concept of eugenics was adopted and applied for various purposes: the genocide of the Jews by Adolf Hitler, in immigration policy and, ultimately, in the forced sterilization of people considered mentally defective, including persons with disabilities. According to the Equal Justice Initiative (2013), in addition to persons with disabilities and prisoners, “thousands of poor Southern Black women were sterilized without their knowledge or consent.”

The notions of Galton and Spencer further fueled views on miscegenation, or biological race mixing, and the legal prohibitions against intermarriage. The supposition was that by outlawing mixed-race unions, the white race would remain the strong, pure race, while mixed-race individuals, called “mulattoes,” would meld into the Black race. It worked. By definition, mulattoes disappeared nearly a century ago after the U.S. census dropped that category and mixed-race individuals were forced to self-identify as Black and intermarry with Black people. Legally, the prohibition on mixed-race marriage lasted until the Supreme Court struck it down in Loving v. Virginia in 1967. But in the dominant discourse, it has lasted much longer. 

Well into the 20th century, the realities of Black mental health were minimized in service to age-old views on the dangers of Black people having too much freedom — namely, that it would cause them to lapse into ruin and insanity. Mental health treatment and facilities were fledgling and limited notions for everyone at the time, but for Black people, institutionalization was dismal. Because of segregation, Black people who were mentally ill were housed separately from whites, to the point of being lodged on the grounds or in overcrowded spaces, forced to work in the facilities, and often hired out to support the institutions.

In some cases, individuals were institutionalized for other disorders, other disabilities were mistaken for mental illness, and people were confined on the word of an employer. Despite passage of the Civil Rights Act of 1964, some states continued to provide discriminatory mental health services in which African Americans were more likely to be labeled as aggressive, less likely to engage in talk therapy, more likely to be segregated on pharmaceutical interventions and, in the case of African American men, more likely to be labeled as schizophrenic and restrained. 

Consequently, many African Americans remain skeptical that mental health professionals are here to help them, and they are often right. According to a fact sheet published by the American Psychiatric Association in 2017, African Americans are less likely to receive “guide-line consistent” care, more likely to use the emergency room or a primary care provider for intervention, and less often included in research. In a 2013 study from Earlise Ward, Jacqueline Wiltshire, Michelle Detry and Roger Brown, African Americans were found to be generally reluctant to consider psychological problems, were concerned about the stigma associated with mental illness, and were “somewhat open” to mental health services, although they preferred “religious coping.” A 2015 study by Janeé Avent, Craig Cashwell and Shelly Brown-Jeffy found that in Southern Black communities, the faith leader or “preacher” is often a front-line source of support for church members experiencing mental health distress. 

To attract Black people to mental health counseling, we must address old prejudices around the flawed construct of race, lingering biases in mental health treatment, and the lack of access to mental health services for those living in poverty. We could recruit more counselor education students from marginalized groups, and we could address the shortage of African Americans among counselor education faculty. According to the 2017 CACREP Vital Statistics Report, African Americans make up just 14.52% of counselor educators, and of that number, 4.11% are African American men. We could ask ourselves hard questions about why counselor education textbooks have been silent about what has happened to African Americans in mental health treatment, and when we do that, we could decide not to put that dialogue in a separate section of the book. 

We could have an integrated discussion about the segregated history of mental health treatment in this country. We could stop saying that Black people “drop out” of treatment and start a conversation about why African Americans are skeptical of our labels and our notions and potions as they relate to the historical regulation of Black behavior. Finally, it is late — but not too late — to do due diligence in the clinical assessment of people who bought and sold human beings and, in many cases, perpetrated horrific acts of violence against them. The victims who resisted oppression were labeled “mentally ill,” but we have yet to label the perpetrators of these atrocities. 

For these reasons, the myths that deny the injustices of slavery or that slavery ever even existed are not benign. African Americans have lived for more than 400 years in a kind of psychological fun house with mirrors that reflect everything in exaggerated shapes. The message: “Your life experience does not matter.” 

Ultimately, viewing enslaved people as less than human, recklessly labeling them and then wantonly disregarding African American mental health for two centuries formed the justification for the Tuskegee experiment. So, if African Americans are reluctant to seek treatment, the reluctance has less to do with race and more to do with trust. That is what the reluctance is about. Happily, that is what counseling is about too.

pixelheadphoto digitalskillet/


Patricia Bethea Whitfield holds a doctorate of education and is an associate professor and coordinator of the CACREP-accredited mental health counseling clinical program in the Department of Counseling at North Carolina A&T State University, where she teaches “Counseling Poor and Ethnically Diverse Families.” She is a member of the North Carolina Counseling Association Executive Council, president of the North Carolina Association for Specialists in Group Work, and past president of the North Carolina Association of Marriage and Family Counselors.


Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit


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.