Monthly Archives: October 2021

Adapting evidence-based interventions for telehealth

By Nicole M. Arcuri Sanders October 29, 2021

The COVID-19 pandemic expedited the push to move mental health services to distance platforms. With providers ethically and legally bound to ensure their clients are not neglected or abandoned, state boards and federal regulators, such as the Health Insurance Portability and Accountability Act (HIPAA), relaxed their guidelines to support all providers in promptly changing how they were used to, and for many, even trained to provide counseling services. The Office for Civil Rights at the U.S. Department of Health and Human Services offered telehealth discretion during the COVID-19 nationwide public health emergency; penalties for noncompliance with the regulatory requirements under HIPAA would not be imposed against covered health care providers in connection with the good faith provision of telehealth during the pandemic. This enforcement discretion is still active with no known expiration date.

This increase in telehealth services has left many providers asking, “How do I actually implement my training of evidence-based interventions (e.g., empty chair, guided imagery) in an online setting?” Ethical and best practices recommend counselors implement evidence-based practices while being competent using the delivery platform (See Standards C.2. and H.1. of the ACA Code of Ethics).

Understanding how to implement counseling interventions using distance platforms is a necessity for counselors now. The purpose of this article is to support clinician understanding of how evidence-based practices can be creatively implemented with clients using a distance modality for a multitude of theoretical orientations.

I use the video conferencing platform Zoom for the technical instructions because it is a widely known and used platform and it offers HIPAA-compliant features. Zoom is accessible on a range of devices such as desktops, smartphones and tablets. Clinicians can use these techniques with other telehealth platforms (e.g.,, thera-LINK), but be aware that the terms and exact steps may change depending on the software used.

Before implementing creative approaches within the distance platform, clinicians should become comfortable and confident in the platform to ensure not only an easier implementation on the clinician’s end but also a clear and concise receipt of the counselor’s intention by the client. Furthermore, these guides do not replace the various ethical and legal implications a clinician must be cognizant of with their telehealth work. Some of these considerations include:

  • Being up to date on state board requirements (Standard H.1.b.)
  • Addressing issues related to the use of distance counseling in the informed consent (Standard H.2.)
  • Verifying the clients’ identity (Standard H.3.)
  • Ensuring electronic records follow security protocols (Standard H.5.)

When you feel comfortable with the ethical codes, legal standards, the modality of services and the platform, you are ready to begin to transform your talk therapy sessions.

Audio and video

There are ways to angle and position the camera when using Zoom to support both verbal and nonverbal exploration. I often ask my clients to move back from their screens so I can see their full body and gain a better sense of their nonverbals. Using wireless earbuds, such as AirPods, can also enhance this experience because not only can you hear when you are away from your screen but you can also freely dialogue while still being able to see the person in full screen. Additionally, you can use the closed caption button on the toolbar if either party prefers this accessibility option.

I’ve found this approach useful when implementing role plays with clients. Seeing the entire person on screen allows me to incorporate techniques I typically use in face-to-face sessions. With the empty chair technique, for example, clients can place an actual chair next to them, which gives clients the opportunity to imagine the person they are talking to is sitting beside them. The client could wear Bluetooth-enabled earphones with microphone capabilities (e.g., AirPods) and move their device, such as a laptop or smartphone, to show their whole body while doing this exercise.

If the client wants to have this conversation with the identified person for the empty chair technique via phone, I may ask the client to act out this scenario by taking their phone and sitting in the area where they would make the call. I would remain on screen and guide the client through this exercise. Clients have reported this approach makes them feel supported and empowered enough to take the next step and actually communicate with whom they desire. This exercise highlights some of the benefits associated with the telehealth platforms because I would not be able to have my client do this activity if we were meeting in a face-to-face setting.

Some clients struggle to imagine seeing this person and share that it’s intimidating for them to talk to an empty chair. So, I ask them to find a digital image of this person and share their screen during the video call, which allows them to talk directly to this image during the session. (Later in this article, I provide directions on how to share your screen to incorporate this intervention.) I can even remove myself from the screen, so the client simply sees themselves and the person with whom they are speaking.

Here are the technical instructions on using the audio and video functions on Zoom:

  • Audio: To turn your audio on and off, click on the microphone icon in toolbar located in the lower left side of the screen.
  • Video: To turn your video on and off, click on the video icon in the toolbar located in the lower left side of the screen.
  • Remove video participant from screen view: To hide your own video, you can either turn your video off by clicking the video icon on the toolbar or by clicking the three-dot icon on the right, upper corner of the video thumbnail and selecting “stop video.” To hide the video of other participants, click the three-dot icon on their video thumbnail and select “hide video participants.”

Virtual backgrounds and filters

The virtual background tool in Zoom can support a number of therapeutic interventions such as mindfulness exercises, progressive muscle relaxation and guided imagery. For instance, I have had clients change their background to a color of their choice and then I have mirrored them by doing the same. Clients have reported that this has limited distractions for them; they simply focus on what we are doing in the present moment because they can only see me and themselves on screen without any distractions in the background.

I have had other clients select a background that offers them a sense of security, lightness or relaxation while we practiced progressive muscle relaxation. I either used the same background as the client or hid my screen, so the client could simply focus on themselves in this exercise. Clients have told me the background provides them with a sense of comfort, which helped them focus on the somatic work.

Some clients have told me that they find guided imagery easier to do in person because they can feel the counselor’s presence in the room, but with distance counseling, they find themselves opening their eyes to check if the counselor is still there, which distracts from the experience. To overcome this obstacle, I often have clients select a virtual background that resembles the one they are imagining. Then if they open their eyes during the exercise, the virtual background can help them regain focus and take them back to their imagined experience.

To use a virtual background:

  1. Click the up arrow beside the video icon on the toolbar.
  2. Select “choose virtual background.”
  3. Choose from preselected options or select your own by uploading an image.

Another option is to have clients use a virtual filter, which blurs the background and makes the client the main focus. This works well for clients who may be timid about sharing their background or if the clinician wants to truly focus more on the client’s nonverbals.

I have found the virtual filter to be especially helpful when working with dance and movement techniques because the filter allows the clinician to better explore the client’s shape, which informs the counselor about the client’s limitations and helps with treatment planning. Clients with a broader movement repertoire, for instance, tend to be able to better cope due to their ability to have alternate means to deal with stress, whereas someone with rigid movement is known to have difficulty relating to others. Ultimately, movement elements provide counselors with insight concerning how a client behaves. In a studio, the clutter that often fills our homes and offices is not present to distract from the experience of movement.

To use a virtual filter:

  1. Click the up arrow beside the video icon on the toolbar.
  2. Select “choose virtual filter.”
  3. Choose from preselected options.

The preselection options include color variants, which can be a creative way to have the client either share their personality or perhaps a bit of their emotion/mood in regard to the day, session or topic being explored.

Screen sharing

Clinicians have the option to share their screen during a video call, and they can also give their clients access to share their screen. This tool can help support the client’s progression toward their goals, and as mentioned previously, sharing audio and video can support mindfulness and guided imagery interventions.

To share your screen:

  1. Click the share screen tool, which is an image of a box with an up arrow, located in the center of the toolbar at the bottom of the screen.
  2. Select the boxes “share computer sound” and “optimize screen sharing” (located in the lower left corner) for video clips.
  3. Ensure the file or video is open on your computer and select the application (e.g., YouTube Video, image) you want to share.
  4. Click “share” in the lower right corner.

Clinicians can use this feature to share psychoeducation services and information or to walk through something together with a client. In career counseling, for example, the practitioner could review jobs with clients or explore a client’s resume and help them identify and highlight strengths or gaps. Screen sharing can also support client accountability with homework assignments. Clients can share journals, charts, supplemental materials (e.g., ABC worksheets), drawings, research they completed, videos, pictures and narrative therapy letters. Counselors and clients can even use this tool to review treatment plans together.

This feature also allows clients and clinicians to collaborate through a virtual whiteboard. I often use a whiteboard when providing an individual check-in with scaling questions so clients can help me define the increments in the scale. This makes the scale more personalized and provides clients with a more active and engaged role in session. Clinicians can save the scale and reshare it in future sessions to modify the client’s feelings or progress or to highlight changes or patterns over time.

Counselors can use screen sharing to incorporate creative approaches with clients. This option allows both the clinician and client to explore a virtual sand tray together despite not being in the same room. (See for a free, interactive sand tray you may want to use with your clients). They could also have the client create visual creations such as drawing on a whiteboard. Counselors can save and reuse these drawings or virtual sand trays at later times with clients if needed. These visual representations are also a nice way to document the session progress.

I often use these tools when doing exposure therapy remotely with clients. If a client has a fear of snakes, for example, then the counselor and client could first read about the fear- or anxiety-provoking item or experience. The counselor or client could share information related to snakes on the screen and together they could process the client’s feelings and reaction to the content. Next, the counselor could display pictures of snakes using the screen share tool. The gradual exposure and processing support a desensitization of the fear, and within time, the counselor could also introduce snake-related videos through screen sharing.

The counselor could even arrange for the client to take a virtual trip to the pet store or zoo. Eventually, the client could take a real-world excursion, and with the help of technology, the counselor could join them remotely. The client could take the device they use for telehealth services (e.g., tablet, smartphone) with them, and the counselor (who would remain on screen) would talk the client through the experience and process it with them in real time.


Telehealth can be much more than talk therapy via audio and video. I hope these guides help support my fellow clinicians in embracing the tools technology offers us to provide clients with enduring evidence-based approaches. Telehealth continues to rise in popularity both by counseling providers and with clients, so ensuring we as clinicians feel confident and competent in adapting our counseling interventions to align in a new platform will not only help us be successful in meeting our clients’ needs but also support the advancement of our profession.

Olga Strelnikova/


Nicole M. Arcuri Sanders is a board-certified telemental health counselor licensed in numerous states, an approved clinical supervisor, and a counselor educator and supervisor. She supervises students conducting distance counseling, and she has participated in research, presentation, publication, and course development for distance supervision and telemental health best practices. She can be contacted 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.

Perspectives on grief and loss

Compiled by Jonathan Rollins October 26, 2021

If you go to the books page on Amazon and enter the word “grief” in the search box, you’ll receive a message saying there are “over 60,000 results” available.

To winnow the choices, you might decide to view only those titles released over the past 90 days. This narrows it down to “over 10,000 results for ‘grief.’’’

Titles published in the past 30 days? “Over 5,000 results for ‘grief.’”

Finally, if you click on books “Coming Soon,” you receive a somewhat manageable “541 results for ‘grief’” (at least that was the case as September drew to a close).

This prodigious output would seem to support the statement that grief is a universal and yet very individualized experience — one that continues to captivate and challenge us as humans. The ever-increasing numbers of books, journal articles and other reports on grief and loss also hint that our thinking about this experience continues to evolve.

Counseling Today recently invited several American Counseling Association members with in-depth knowledge in the area of grief and loss to share their insights on specific aspects of grief that they believe to be largely overlooked or misunderstood. 


Maintaining continuing bonds with the deceased

By Kenneth J. Doka

In recent years, there have been significant challenges and changes to the understanding of grief. These changes include such aspects as:

  • Extending the understanding of grief from reaction to a death of a family member to a more inclusive understanding of loss
  • Acknowledging that there are no universal stages in grief and recognizing the very personal pathways that individuals take when experiencing loss
  • Recognizing the multiple and multifaceted reactions that people have toward loss (rather than seeing grief as primarily affect) and the ways that responses to grief are influenced by culture, gender and spirituality
  • Seeing the possibilities of transformation and growth in mourning rather than coping passively with loss
  • Moving from understanding grief simply as a normal transitional issue to recognizing its more complicated variants and the necessity for careful assessment
  • Acknowledging that certain individuals show great resilience as they cope with loss and grief
  • Maintaining a continuing bond with the deceased rather than pushing to relinquish ties to the deceased 

It is this last area of continuing bonds where I wish to focus. Sigmund Freud, over a century ago in Mourning and Melancholia, argued that bereaved individuals must detach from the deceased by withdrawing emotional energy from the person who has died and reinvesting it in others to go forward with a healthy life. 

This notion has been deeply challenged in recent years. In their groundbreaking 1996 book Continuing Bonds: New Understandings of Grief, Dennis Klass, Phyllis Silverman and Steven Nickman drew on research with bereaved children, spouses and parents, as well as teachings of Eastern religions, to both emphasize and demonstrate the importance for many bereaved persons and groups to maintain an ongoing connection to the individual who has died. They stressed that connections of this type were comforting and eased the grief of those who were bereaved.  

Bonds are maintained in several different ways. First, we always retain memories of the deceased. This is critical. Many bereaved individuals fear that as they cope with loss, those memories will fade. This exacerbates their sense of loss and impedes the grief process. Counselors should affirm to clients near the beginning of grief therapy that the goal is not to diminish memories of the deceased but rather to help them find comfort in such memories as the pain of loss lessens. The amelioration of grief means that over time, the intensity of the grief experience lessens, and individuals function in ways comparable to (or perhaps even better than) the way they did prior to the loss.  

The fact that these memories are always retained is also a reason for subsequent surges of grief that may occur years after the loss. For example, think of a young woman whose father died when she was a little girl. Two decades later, as she walks down the aisle to be married, she has deep pangs of grief that her dad is missing this event. In fact, at the termination of a counseling relationship, it is helpful to suggest, and even to identify, the significant life events or major transitions that might generate such surges of grief in clients.

Second, important attachments become part of one’s own biography. We are influenced by so many factors. The ways that one interacts with others who are important in one’s life frame an individual’s personality. In addition, significant attachments in one’s life leave their legacies, and sometimes their liabilities, on the identity of the bereaved individual. Those legacies (and sometimes liabilities) can include everything from personal gestures to beliefs to the ways that one views self and relates to others and the world. 

Third, survivors retain spiritual ties such as the belief that the deceased is interceding for them (or will intercede) and that they will be reunited in an afterlife. Many spiritual systems have beliefs and practices that strive to retain a connection with the deceased, such as Roman Catholic Anniversary Masses or the Jewish Mourner’s Kaddish — a prayer said at the memorial service as well as for 11 months following the person’s death. In fact, Klass’ interest in Eastern religions was one influence on the development of his theory. Klass pointed out that in traditional Chinese worship, the veneration of one’s ancestors was a common practice that served to reinforce a continuing family bond across generations.

Furthermore, many bereaved persons report extraordinary experiences in which they have sensed the continued presence of the deceased in their lives, whether it is dreaming about the deceased or other ways in which they believe they have encountered the deceased. Such experiences are, in fact, quite common in bereavement.

Finally, increasing numbers of bereaved persons are using the internet and social media, particularly Facebook, to provide death notifications and to continue ongoing relationships with the deceased. For example, they may visit the Facebook page of the person who died, comment there on pictures, post memories and even leave messages to the deceased. It is not unusual for mourners to “keep alive” the digital identity or Facebook page of a person who is deceased. 

Continuing bonds can be applied to groups, communities and even nations. Communities may name parks, streets or buildings after individuals or erect memorials to the person. Nations may honor ties with deceased leaders by naming cities after them and building monuments or establishing holidays to celebrate them.

While continuing bonds are generally healthy, they can at times be problematic when we fail to acknowledge the death or are burdened by promises made to the deceased prior to death. For example, one client, a young widow, promised her spouse prior to his death that she would never remarry. Now she feels torn between her promise to her dead husband and her desire to engage in a new romantic relationship. 

Continuing bonds are natural and normal responses in bereavement. Yet we need to guide clients so that these bonds do not become chains that inhibit their adaptations to loss and perhaps even their personal growth.

Kenneth J. Doka is professor emeritus of counseling at the College of New Rochelle and senior vice president for grief programs at the Hospice Foundation of America. Contact him at



School counseling: Grieving children and adolescents

By Jillian M. Blueford

We often see grief as a common reaction to loss, but at times we try to separate it from who we are and who we want to be. We treat grief the way we treat many life stressors, tending to what is most immediate in hopes that one day, that stressor will be a thing of the past — something we have “overcome” or “persevered” through. However, grief involves a lifelong shift that does not work on a timeline or according to expectations. 

This experience is especially true for children and adolescents, who are not immune to grief and who could have a longer time to navigate their grief while anticipating additional losses in the future. Grief can permeate every aspect of life, and it affects children and adolescents in ways that are as unique as they are during these fast-moving developmental stages. Reflecting on my professional experiences counseling grieving children and adolescents, I have yet to encounter two young people with the same grieving response.

Although we have established that a child’s or adolescent’s response to loss will vary and can appear at any time, we can expect for their grief to influence their presence at school. School is a significant part of many children’s and adolescents’ upbringing. So, naturally, their grief might make an appearance in the classroom, in the cafeteria, on the playground, at sporting events, during choir performances, at club meetings and elsewhere. 

This also means that school counselors may be called on to provide services. These services are often introduced after a school staff member is made aware that a student has endured a death-related loss. According to Judi’s House/JAG Institute, 1 in 14 children in the U.S. will experience the death of a parent or sibling by age 18. This statistic does not account for the deaths of other family members, friends or community leaders, nor does it cover the nondeath losses that children and adolescents endure (e.g., moving, separation of caregivers, pandemics, changes in health, financial instability). COVID-19 has shone a light on some of these losses, but the truth is that many of these losses happen so frequently that we do not recognize these changes as they happen, nor do we seek to understand how children and adolescents grieve these losses long term.

In my experience providing counseling services in schools and outpatient settings, I have often been asked, “What does grief look like for children and adolescents?” I perceive this question to mean “what behaviors stand out for grieving children and adolescents?” But I tend to shift the focus to time and circumstances. 

When we first encounter a loss, it can throw many of us for a whirl. Our appetite, sleep patterns and engagement level with our relationships may be affected. It is typical and expected to be bombarded with an influx of thoughts and emotions. This is no different for children and adolescents who experience a loss.

Furthermore, I expect the academic performance of children and adolescents who are grieving to change. I expect them to become more distracted in class, to potentially distance themselves from others, and to ask more questions about death and the safety of their world. I particularly try to understand how recently the loss occurred and the relationship or attachment the child or adolescent had with what they lost (e.g., a person, experience, material item, health). Those markers give me a better idea of how the child or adolescent has been responding and areas within their grieving process that negatively affect their daily activities over time.

If we tend to focus only on the losses that children and adolescents endure during an academic year, then we may forget to ask about their history of losses. Having this information can help us conceptualize current grieving responses that may otherwise feel sudden and unusual. Understanding the timing also helps illuminate “re-grief,” or the understanding that as children and adolescents mature, their recognition of their losses will change. This can lead to a resurgence of grief, especially as children and adolescents reach developmental milestones, many of which happen while in grades pre-K-12. 

On top of the other responsibilities that school counselors have, fully addressing a child’s or adolescent’s grief can be overwhelming. Given that grief does not have an end date, engaging with grieving students is an ongoing responsibility and requires different care and attention levels. School counselors may believe they have already put in intense effort to support a grieving child or adolescent, but in fact this effort requires a lot of ongoing listening, empathy, validation and education.

Any adult can benefit from a refresher on how children and adolescents respond to a loss. I have seen these educational conversations make all the difference when students are mislabeled as “problematic” but are really just having a difficult time with their grief. Caregivers and families, who are often grieving themselves, can especially benefit from understanding the unique aspects of child and adolescent grief. School counselors should identify resources and strategies that adults in other environments can use as well. 

The organizations listed below provide curricula, podcasts, interactive activities and strategies supported by data. Share these resources with families and any adult who interacts with children and adolescents.

  • Coalition to Support Grieving Students
  • Judi’s House/JAG Institute for Grieving Children and Families
  • The Dougy Center
  • National Alliance for Children’s Grief
  • National Center for School Crisis and Bereavement
  • Grief-Sensitive Schools Initiative

In addition, connect with local counseling professionals, particularly in bereavement settings. Often, these organizations will host grief camps and services for children, adolescents and their families at little to no cost. They can also serve as consultants to supplement your understanding of grief and loss and perhaps provide in-person individual and group services.

My first experience providing counseling was through my time as an intern for a hospice bereavement center. In visiting schools and facilitating grief groups, a passion was sparked in me for addressing grief and loss. It was the school counselors who often advocated for our services, referred families and empowered grieving children and adolescents to believe that they were cared for and not alone in their grief. 

Jillian M. Blueford is a licensed professional counselor, national certified counselor and clinical assistant professor in the Department of Counseling Psychology at the University of Denver. Her primary research expertise falls under grief counseling training and preparation and counseling grieving children and adolescents. Contact her at



Working with military grief of noncombat deaths

By Joanne Steen

In the United States, there seems to be a widely held belief that military personnel die only in war. However, total military deaths since 9/11 paint a much different picture of how and where U.S. service members have died. In the first seventeen years after 9/11, a total of 22,365 U.S. military personnel died on active duty, according to the Department of Defense (DOD). Of this number, 31% died in Iraq or Afghanistan, while the remaining 69% died in the line of duty, but not in armed combat or war. 

These statistics are surprising to many, and they emphasize a sobering reality of military service: Military personnel regularly die in the line of duty, both in peacetime and in war. 

I learned this lesson the hard way. I married a Navy pilot several years before 9/11 and never worried when he flew. He loved to fly, was well-trained, and the U.S. was not at war. Life was better than good — until the day the helicopter he was flying exploded in midair as he and his six-person crew were returning to Naval Station Norfolk in Virginia. There were no survivors.

War deaths embody the ultimate sacrifice made by military personnel in the defense and protection of our rights, freedom and homeland. But apart from armed combat and war, service members also lose their lives in other military operations worldwide; in terrorist attacks at home and abroad; in training to maintain their operational readiness levels; because of accidents, equipment failure or human error; by suicide or homicide; and because of illness and disease. 

Counselors who work with surviving families or veterans benefit from knowing these common causes of death in the military, because how a service member died is very important within the military culture. The cause of death can deprive survivors of validation of their loved one’s service and unfavorably affect the support they receive.

Prior to 9/11, there was little in the way of literature and military-focused grief resources for family members or professional service providers. Survivors such as myself struggled to cope with this life-changing loss and a grief that few others seemed to fully grasp. The grief constructs of prolonged grief disorder or complicated grief didn’t easily adapt to military grief. As a survivor, I sometimes felt like a fish out of water, isolated in military grief and unable to chart a path forward on my own. 

In hindsight, here are three things I wish my therapist and I had known when my late husband was killed. 

1) Military grief has a long shelf life. Military grief can be complex, complicated and messy. Contrary to another popular belief, military families are not prepared for the loss of their loved ones.

Like a perfect storm, military grief is the result of the intersection of three powerful circumstances: the death of a loved one who died much too early in life (the average age of death is 28, according to the DOD); the high likelihood that death was sudden, unexpected and potentially violent in nature; and the unique factors that military service brings to death. A few of these factors include a sudden death far from home; a traumatic notification and casualty assistance process; limited details or classified information; unrecoverable, unviewable or partial remains; the soul-searing traditions of a military funeral; and the realization that common symbols of our country, such as the American flag, have become personal symbols of loss.

Some military families live on base or post, and when their service member dies, they are given a limited time to relocate off the military installation. When Laura Monk asked for a few more weeks to move off post after her husband, U.S. Army Specialist Austin Monk, died of leukemia at age 22, her request was denied. “All the grief books I had read said not to make any major decisions the first year,” Laura recalled, “but before I was ready, I had to leave the home Austin and I shared, plus my support network on post.” 

2) Noncombat deaths can be marginalized and the associated grief disenfranchised. In many areas of our country, knowing a military family is the exception rather than the norm. As a result, the challenges faced by these families and veterans are often unrecognized or misunderstood. 

Couple this limited awareness with the pervasive belief that military personnel die only in war, and the families who experience noncombat losses often find their service member’s death marginalized. U.S. Air Force Master Sgt. Steven Monnin battled posttraumatic stress disorder before ending his life in 2004. His surviving spouse, Elizabeth Monnin, recalled going to an event in support of surviving families and seeing an object that was akin to a traveling memorial. When she inquired if her husband’s name could be added, she was asked how he died. After Elizabeth explained, she was told, “No, this is for real heroes.” While not all replies are this extreme, many conversations send a not-so-subtle message that combat deaths garner more appreciation and greater respect than do noncombat deaths. 

3) Finding meaning in noncombat deaths can be challenging. Families of military personnel who were killed in armed combat or war usually find meaning in their loved one’s direct actions to protect or defend the nation from those who want to do great harm to America. They find purpose in their loved one’s ultimate sacrifice for the greater good.

But what happens when the death seems senseless? Finding meaning in a live-fire training accident or an exploding helicopter can be difficult. Families sometimes turn to making meaning out of their loved one’s life rather than their death.

My search for meaning in my late husband’s death was long and painful. Eventually I concluded there was no great meaning in his death, but I found renewed meaning in his short life. He loved his family, loved his country and loved to fly. He was simply one of the good guys and was memorialized by his commanding officer as “the man every father secretly hopes his daughter will bring home.” What more did I need to search for? 

Joanne Steen has more than 20 years’ experience as a national certified counselor, author, and educator on grief, loss and resilience, with a specialty in traumatic and line-of-duty losses. She is the co-author of Military Widow: A Survival Guide and the author of We Regret to Inform You: A Survival Guide for Gold Star Parents and Those Who Support Them. She is the founder and principal consultant of Grief Solutions, which offers customized training and resources on grief. Contact her at



‘You aren’t grieving correctly’

By Claudia Sadler-Gerhardt

“Why are you still wearing your wedding ring?”

“You shouldn’t be dating yet. It’s too soon.”

“Why aren’t you dating yet? It’s been long enough.”

“Your kids need a dad. Find another husband.”

“Are you really still sleeping in your marital bed? Still living in the same house?”

“Plenty of divorced people are single parents, so this isn’t any different.”

Losing an intimate partner is profoundly life-altering at any time, but for a young adult (those ages 20 to 40), the loss is atypical and unexpected. There also appear to be societal expectations regarding what such off-time widows or widowers should do or should not do during this time of grief. Research supports that partner death increases the risk of physical and mental health concerns, including depression and anxiety, financial insecurity, loss of identity and loss of social connections. For the young widow or widower with children at home, becoming a sudden and unexpected single parent and the only income earner can be overwhelming. 

There is a paucity of research and literature about off-time widowhood. There is also a lack of role models for the young widow or widower because cohort members are unlikely to have lost partners. Additionally, there is ambiguity about what behavior is socially acceptable for this age group. Support programs are often geared toward widows or widowers in later stages of life who have different needs and concerns than the younger widow or widower does. In addition, young parents who are simultaneously working and raising children have a lack of discretionary time for obtaining grief support.

Given the current COVID-19 pandemic, the continuing opioid crisis and high rates of motor vehicle accidents, it is likely that rates of young spousal death may increase. A colleague and I recently conducted a qualitative research investigation (unpublished) with six young widows and one young widower (all 20 to 40 years of age) whose partners had died within the past 10 years. We hoped to learn about their lived experience of widowhood, including relational, financial, parental and personal changes resulting from the death of a spouse or partner. 

The first blatant phenomenon was that all of these widows and widowers had been told by someone that they were not grieving or acting correctly. Most of the issues revolved around when to date again (or not), when to remove wedding rings, when to change beds and whether to allow children to join the parent in the bed, and how to relate with their in-laws. Comments ranged from “children need a dad/mom” to opinions that it was way too early for the widow or widower to be dating. Another concern was the awkwardness of possibly dating someone who had known the spouse before their death. In-laws often disapproved of the surviving spouse returning to dating because that could essentially result in their adult child being “replaced” in the family. Additionally, it can be challenging for the surviving spouse to interact with or to maintain a relationship with their in-laws after the death of their spouse.

Another big change involved social and friendship relations. The participants reported losing friends who were uncomfortable having someone who was now single in a group of couples. In addition, friends were often uncomfortable asking or talking about the spouse or partner who had died, under the guise of not upsetting the griever. Widows reported feeling as if they didn’t fit in. Many were encouraged to “move on,” to remember that they were still young and needed to find someone to be with. Others were told that being widowed was similar to being divorced. Although in death, unlike with divorce, there is no other parent to help out.

Another big area of struggle related to identity. Who is this person now that they have been widowed? Are they still married or suddenly single? Stereotypical widows are not 40 years old. The young widow or widower often deals with being the only wage earner, a solo parent and the primary housekeeper and has little time to work on self-identity. 

Most of the participants in our study were parents who expressed a need to stay healthy for their children. Children often were scared that the surviving parent might die. Work, parenting and other tasks left little time for the surviving parent to engage in self-care or grief support. Finding some semblance of balance was challenging. Social media was a convenient resource for helping these individuals learn about grief and obtain supportive networks. There are online groups for young widows, and there are also hospice services for their families. Making time to exercise was another challenge that was noted, although most of the study participants acknowledged its importance. 

I have worked with many grievers for several years, taught undergraduate and graduate grief counseling courses, and presented numerous grief workshops. So, what have I learned about young off-time widows and widowers from a clinical counseling perspective? 

Assessment is absolutely critical. Do not make assumptions. Assess from a biopsychosocial-spiritual perspective. Obtain referrals if appropriate. Assess family and in-law relationships.

Recognize the unique needs of the widow’s or widower’s developmental stage.

Give consideration to the utility of telehealth appointments if appropriate.

After ensuring that basic needs are being met, work with the widow or widower on areas such as identity and roles, social support, self-care and grief support. 

Be aware that widows and widowers will likely experience others telling them how to grieve in the right way. Foster their ego strength in making their own decisions. 

Above all, be a safe companion for these grievers while allowing time for their stories to be shared. 

Claudia Sadler-Gerhardt is a licensed professional clinical counselor with supervision designation in Ohio. She is a past president of the Association for Spiritual, Ethical and Religious Values in Counseling, a division of ACA. Contact her at



Behavioral manifestations of grief in young clients 

By Rebekah Byrd

I had been working with Kai in play therapy for about six months because he was at risk of being kicked out of his third preschool due to problematic behaviors. He had been working hard and making progress but seemed to regress and was also experiencing a recent and intense overdependence on his mom. 

Jordan, an adolescent, was referred to me because he was having explosive emotions. His temper tantrums had become so aggressive that his grandmother no longer felt safe around him.  

As counselors, we are often working with children and adolescents because of an identified behavioral issue. We know that the presenting issue is rarely the problem. Rather, it is often a behavioral manifestation of the real underlying concern. Similarly, other reasons for seeking counseling services, such as anxiety or depression, are frequently manifestations of unrecognized grief and loss that have been unidentified, untreated or, often, misdiagnosed.

It is imperative that we remember and help other important figures in a child’s and adolescent’s life understand that what adults may understand as grief and loss might look very different for children and adolescents. Many of the concerns raised in Kai’s and Jordan’s cases are behavioral manifestation of grief. Regression, volatile emotions, acting-out behavior, temper tantrums, overdependence, a constant demand for attention, and aberrant activity are all common manifestations of grief among children and adolescents. The question is, how often do we miss these? 

In the third edition of his book Play Therapy: The Art of the Relationship, Garry Landreth noted that when we focus on the problem, we miss the child. In my experience, children and adolescents are always communicating. Kai told his parents that his teacher had died. He was struggling to understand this. His parents assumed he was regressing into his old ways of lying. They were in disbelief that we had come so far in six months only to be right back where we started. Kai’s behavior had amped up to a level that seemed worse than when his preschool teachers were stating that he was at risk of losing his spot in the school’s program.  

Full of frustration, worry and fear, Kai’s parents were asking me what to do. I understood that Kai was dealing with some very real themes of death and dying in the playroom. He was doing difficult work and trying to process these concepts through play in a very real way. I encouraged the parents to see these behavioral concerns as symptoms of grief and loss instead of assuming that Kai was reverting to old behaviors. We turned our focus to the child rather than on the problem.  

Almost immediately, Mom started sobbing. She kept saying, “The assistant T-ball coach!” Dad then realized what was happening. They both remembered that Kai’s assistant T-ball coach had recently passed away. When Kai reported that his teacher had died, his parents had dismissed it as a lie, never considering the impact that an assistant T-ball coach could have on their 4-year-old and not thinking about how many 4-year-olds call any adult who works with them their “teacher.” 

The parents felt awful that they had dismissed Kai’s real feelings of grief and loss and had also missed the opportunity to comfort him when he reached out to them using his words. (This was a major accomplishment for Kai, as it would be for most 4-year-olds who don’t understand grief and loss, much less why they are feeling such strong emotions.) The parents felt ridiculous for not putting this together sooner, and we were able to process that.  

As counselors, we don’t always have this information, and as school counselors, we might not meet with parents or other important adults as much as we would like in order to put these pieces together. So, it is imperative that we recognize the many facets of grief and loss and the impact on children and adolescents so that we can assist in the healing process.

Jordan had suddenly lost his mom, and his grandmother was now his guardian. His loss was front and center for him and for those around him daily. However, his family had thought that Jordan had already worked through the loss of his mother. These “new” behaviors he was exhibiting (explosive emotions, temper tantrums, aggression) were treated as somehow being separate. It can be easy to assume that caregivers will make the connection between an adolescent’s acting out and their experience of grief, but what happens when the family/caregiver doesn’t see it that way or is too mired in their own grief and loss and is triggered by what this is bringing up for them?  

When parents or caregivers are also grieving, adolescents may keep their sorrow to themselves. They may feel pressure to be “OK,” or they may feel responsible for not causing their grieving parents or caregivers further distress. 

In addition, adults may recognize the issue of “primary loss” with children and adolescents — the substantial loss that often refers to the death of a loved one (in this case, Jordan losing his mother) — but overlook or lack awareness of the many secondary losses. “Secondary loss” refers to all the subsequent losses associated with the primary loss. In Jordan’s case, the secondary losses included losing his sense of safety and attachment to the world, his main source of support, his family role, his carefree attitude and happiness, his home (his mother’s death meant he needed to move in with his grandmother), his regular bus route and bus ride with familiar faces, and the list goes on and on.  

Counselors must also understand how culture plays a role in child and adolescent processing and displays of grief and loss. Many types of grief and loss exist (e.g., ambiguous loss, anticipatory grief, complicated grief, delayed grief, disenfranchised grief, traumatic grief), along with different models for engaging in this process. Counselors must be able to recognize, acknowledge and affirm needs associated with grief and loss issues to assist clients in their healing journey. Because children and adolescents are not always able to verbally process feelings, the use of play therapy and expressive arts may be essential to the process of helping them cope and heal.

Rebekah Byrd is a licensed professional counselor in Tennessee, a licensed clinical mental health counselor and licensed school counselor in North Carolina, a national certified counselor and a registered play therapist supervisor. She is an associate professor and director of the Institute for Play Therapy and Expressive Arts Education and Research at Sacred Heart University and co-author, with Chad Luke, of Counseling Children and Adolescents: Cultivating Empathic Connection. Contact her at



Helping professionals and the experience of personal loss

By Barb Kamlet

Two significant worlds collided in my life on Aug. 28, 2006. On that date, I started graduate school to earn my master’s degree in counseling and, earlier that day, my father and my family learned of his terminal diagnosis. In my first journal entry for my first class, Cultural Issues and Social Justice, I wrote the following: “Today I learned about two new cultures — those who believe they are living and those who know they are dying.” 

It was a poignant and challenging time to be the grieving daughter of my dying father as I was going to graduate school to become a grief counselor. During the next 21 months, until my father’s death, I discovered yet another culture — that of helping professionals experiencing personal loss. It was a time filled with painful support gaps and myriad self- and other-imposed expectations that, as a therapist-to-be, I “should” already possess whatever coping skills I would need to navigate through the experience of my dad’s illness and death.  

I rose to the occasion by confusing my roles. I became the counseling professional in interactions with my family — interpreting what I thought they needed to know and screening out what I thought they didn’t — and the grieving daughter with my colleagues — people who couldn’t remotely understand the relationship I had with my dad or the grief I was experiencing. Clearly, this was my way of avoiding what was really going on inside me.  

Perhaps it was because I was working as a hospice grief counselor where my dad died that those expectations were so prevalent and that my questions eventually became twofold: Was I the only therapist who felt like this and, whether I was or not, could I go someplace for support where I wouldn’t be known, where I wouldn’t be using my “therapist brain” and where I wouldn’t run into my own clients if I chose to attend a grief support group?  

Sadly, when I tried to research grief support for hospice professionals for my group’s class project, there wasn’t much, if any, to be found. So, real-time research became my invaluable go-to. In the course of that research, I learned there were other counselors and helping professionals who were experiencing similar challenges around their own personal losses. 

Many spoke about a logistical challenge: In trying to find their own grief counselor, they faced a very real possibility of creating a dual relationship, particularly if they lived in a small community. Another common theme that echoed my own experience was the self- or other-imposed pressure to stay in role as a counselor, particularly with other grieving family members and counselor colleagues. Yet another widely expressed concern centered on the issue of transference, countertransference and possibly crossing professional boundaries when sitting with their own grieving clients. One interviewee expanded on that challenge, stating, “As a provider of grief support myself, this also led to my delayed reaction, as when I felt something, I intellectualized it.”

As Marion Conti-O’Hare wrote in The Nurse as Wounded Healer: From Trauma to Transcendence, “All too often … health professionals are reluctant to reveal themselves because of the potential for vulnerability, created largely by an orientation toward perfection and flawless performance.” For counselors and other helping professionals, hiding behind their professional role can serve as a protection or mask that allows them to compartmentalize or intellectualize their own grief. This is a means of avoiding potential vulnerability and the painful feelings of grief that we encourage our clients to journey through. 

As a result of my research, I have had the opportunity to present at several national conferences, and the question I am asked most frequently is this: “We have a colleague whose loved one died recently, and we’re wondering how to help.” Knowing the challenges that we, as grief counselors, experience around finding our own support when we are grieving, I think the answer is a simple one. We should do just what we do for our clients and other grieving people in our lives — meet them where they are and ask them to share their story. Pervasively during my research, grieving colleagues, much like our grief clients, wanted the opportunity to share their story and have it heard without judgment.  

A grief counselor captured the essence of that need when she wrote: “This time has been utterly transformative as I have experienced it through many lenses of the heart and mind and soul — and with both personal and professional perspectives. It would help me to be able to share this with someone interested in the many facets and [to be] able to ask questions that might assist me in organizing, integrating and reconciling my experience.”  

Another colleague wrote more succinctly, “Not sure if you’ll find any added themes from my story, but I felt like sharing it anyway as a way to deal with my own grief.”

To paraphrase something ACA President S. Kent Butler wrote recently in his column for Counseling Today, when it’s us as counselors who are the bereaved, can we allow ourselves to be our human self rather than our counselor self? I challenge every counselor working with grieving clients to be the role model for your clients and for our grief-denying society at large by giving yourself the grace to be your human self when you find yourself in that sacred space of grief.

Barb Kamlet is a licensed professional counselor and national certified counselor. Her private practice, GriefJourney Counseling PLLC, is in Aurora, Colorado. In addition, she is the co-founder and executive director of Shimmering Wings, a nonprofit dedicated to providing support and resources to individuals who have experienced a childhood death loss. She continues to do hospice grief counseling. Contact her at



Jonathan Rollins is the editor-in-chief of Counseling Today. 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.

Voice of Experience: A not-so-simple question

By Gregory K. Moffatt October 21, 2021

I have a feeling some of you will stop reading after the next paragraph. You could be excused for thinking, “This is so basic.” But even if you are a seasoned professional, I ask you to hang with me for a bit. The question I pose might not be as basic as you think.

Here is the not-so-simple question: Should counselors contact their clients by email or text to confirm appointments?

It is common practice to send such messages, and perhaps they are even necessary. After all, for every no-show, we often lose money. And forgetfulness and disorganization are sometimes part of our clients’ dysfunction, so reminders might be in their best interest.

As subtle as it may seem, a reminder/confirmation message is a boundary crossing. There is nothing inherently wrong with a boundary crossing (as opposed to a boundary violation). Still, we should always carefully examine the possible ramifications of any boundary crossing.

Let’s ask another question: Should we call our clients on the phone to confirm their appointments? I suspect most of you reading this would say no.

And one more question: Should we drop by our clients’ homes or workplaces to remind them of their appointments? Surely no one would think this kind of boundary violation is ethical.

Brett Jordan/

So, what is the difference between an email and dropping by someone’s home? Don’t get me wrong. By no means am I proposing that these three scenarios are the same, but I am suggesting that they have something in common. In all three cases, we are crossing a boundary. Even with a simple text or email, we are figuratively stepping into our clients’ private worlds, potentially without invitation (I’ll come back to this in a minute). In this way, a text message is similar to standing at your client’s front door.

When that text or email goes through, we don’t know who might have access to it besides our clients. We don’t know what potential problems that might cause or what potential embarrassment or intrusion our clients might feel.

Would they feel obligated to explain who you are as a counselor? What if there are difficult relationships, jealously, distrust or other powerful and emotional dysfunctions in operation? Or what if our clients simply choose not to make others aware that they are seeing a counselor? This is why the question isn’t so simple.

When anyone — another professional, another client, a friend, a relative — comments about one of my clients, my response is always the same: “Who my clients are or are not is no one’s business but theirs.” This simple piece of information should be guarded as carefully as any secret our clients choose to share with us.

I’ve often thought about past clients and clients who dropped out of therapy without closure. I’ve wondered whether I should reach out to check on them or to ask if they would like to reschedule. But I never do, even when the urge to follow up is powerful.

If I reached out to them, a host of things could happen. They might feel obligated to come see me. As in the scenarios mentioned earlier, I might complicate their lives or embarrass them. Maybe they didn’t like me as a counselor but didn’t want to confront me by saying, “You haven’t really helped.” We protect all of that by not intruding into our clients’ lives.

But this doesn’t mean that we can’t send reminders or follow-ups. The easiest way to manage this is to include this information in your informed consent. At the end of my informed consent is a section where clients can check off the ways they approve for me to communicate with them. These options include phone (landline or cell), email, video (Zoom), chat and text. I note which options are HIPAA compliant and which are not.

I also include a section regarding clients’ preferences for receiving session reminders and messages about missed appointments. “None” is an option. This section of my informed consent is where clients extend me the “invitation” that I referred to earlier.

Thus, I’m not suggesting that we never send follow-ups or reminders. It is a reasonable and commonly used business practice that is not inherently unethical. But it would be very easy to never even ask the question regarding its effects because it seems so innocent.

If you decide to use these tools, keep three quick rules in mind.

  • Rule No. 1: Keep it short.
  • Rule No. 2: Keep it professional.
  • Rule No. 3: Keep it vague so that your client will know who you are, but it won’t be so obvious to others. For example, “Reminder of our meeting, Wed., Oct. 10, 3 p.m.”

In this way, we can protect our clients.



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.

Addressing sexual violence among teens

By Leontyne Evans October 13, 2021

Intimate partner violence is increasing at an overwhelming rate among teens and young adults. Because of this, sexual violence is also increasing. Due to the lack of education and awareness in this area, it often goes unreported to authorities.

To better understand the topic, we first have to define it. Sexual violence involves forcing or attempting to force a partner to take part in a sex act or sexual touching when the partner does not or cannot consent. It also includes nonphysical sexual behaviors such as posting or sharing sexual pictures of a partner without their consent or sexting someone without their consent.

While facilitating groups and programs with young people in Omaha, Nebraska, I found that 3 of 10 participants were victims of sexual assault by a partner and didn’t know it. They were unaware that the actions of their partner were classified as abuse.

This has been consistent with all groups, classes and programs that I have facilitated. It is important to bring awareness to how under-reported this issue is among youth. In many cases, it’s not only those who have been victimized who are unaware they have experienced sexual violence. Believe it or not, the perpetrators of such abuse can lack awareness that they are using abusive tactics such as manipulation and coercion.

The need to talk about sex

A lack of education in this area exists in part because it is typically seen as taboo to talk about sex and consent with youth. Among those who are victims of sexual violence, physical violence or stalking by an intimate partner, 26% of women and 15% of men report that the abuse or other forms of violence took place before age 18.

Many parents think that talking about sex will encourage their children to engage in sexual activity before they are ready, despite there being no solid research to support this belief. So, because parents aren’t teaching it at home and because the sex education being taught in schools is pretty much limited to “have sex and you’ll get pregnant or catch a sexually transmitted infection,” many youth don’t have a proper understanding of what consent actually is.

Some victims believe they have to have sex with someone because it’s their “job” as a partner. The urban proverb of “what you won’t do, someone else will” reigns in the heads of our youth, making them believe they must have sex to keep a person’s interest. There are also young people who have not been taught to accept the word “no,” so when their partner says it, they don’t believe it or accept it. They either continue to try until their partner gives in or they become aggressive because they feel “disrespected.” This is the behavior we must bring attention to as counseling professionals. But to do that, we must figure out where it starts, how it starts and why.

Overall, youth who offend are more likely than youth who do not offend to have backgrounds involving fetal alcohol spectrum disorders, substance abuse, childhood victimization, academic difficulties or instability in the living environment. Studies performed on youth offenders show that youth who have been faced with adversity are at a higher risk to offend. These studies seem to be suggesting that these problems are rooted in familial dysfunction.

The message of entitlement

My work with youth has exposed several issues with parenting when it comes to young people understanding and accepting the word “no.” Many parent do not seem to grasp that every decision they make will have an impact on their children one way or another. Raising entitled children may not seem like such a big deal when they are younger, but those small, cute children have to grow up someday.

Not telling a child “no” to avoid hurting their feelings or hearing them cry is common. We want to protect our children from the harsh realities of the world and try to soften the blow by giving them the things that make them happy. But what happens when that child turns into a teenager and can’t accept the concept of “no” because they literally don’t know how. What happens when that sweet baby grows up learning that “no” doesn’t really mean no? That if they keep asking, become aggressive, act intimidating or annoy someone enough, that “no” can turn into a “yes”?

Kids who can’t accept no for an answer or perceive rejection as a form of disrespect take these behaviors into adulthood and are more likely to abuse. Once again, it may not be intentional. They may not even see themselves as abusers. This has simply become their norm, a learned behavior that has been accepted rather than corrected, leading them to believe that the person saying no is the one with the problem — not them.

Working together

In the counseling profession, we not only have the ability to work with youth victims and perpetrators; we can also offer support to the adults in their lives. We can speak to the importance of supporting the development of healthy, respectful and nonviolent relationships. It is critical that we take advantage of our access and give parents tips on how to navigate through these tough situations.

During the preteen and teen years, it is critical for youth to begin learning the skills needed to create and maintain healthy relationships. These skills include knowing how to manage feelings and how to communicate in a healthy way.

We can all work together to end the cycle of teen dating violence and teen sexual violence by encouraging adults to create safe and brave spaces for our youth. This involves creating spaces at home and school where youth feel safe to come to an adult to have open and honest conversations. It should be a place of trust and support, not judgment and anger.

Youth also need examples of healthy relationships. If children have been subjected to unhealthy relationships, parents should consider seeking professional help for their children to process their feelings toward what they have witnessed.

We often focus on making sure that adults involved in domestic violence situations are connected to programs and services, but we tend to forget about how children are affected by the abuse. As we encourage adults to seek counseling, we should encourage them to seek therapy for their children as well. Second-hand violence is just as impactful as firsthand violence.

Gaelle Marcel/

Being willing to be uncomfortable

In working with youth, we need to get used to the idea of introducing the concept of consent and safe sex at an early age. Contrary to popular belief, this will not encourage youth to have sex. It will, however, ensure that they are properly educated and prepared when they do decide to engage in sexual activity.

We also have to start having the same conversations with boys and girls. We can’t teach our girls about consent and not our boys. We can’t see only our girls as having the potential to be victims and not our boys. All children should be provided with the same knowledge, skills and tools to combat abuse.

Finally, we must create the possibility for prevention. Sex education should include more than discussions about pregnancy and sexually transmitted infections. Safe sex should refer not only to using condoms and contraceptives but also to discussing actual safety. Safety includes consent, mental and emotional safety, physical safety, the environment, etc. Using a condom does not make sex safe.

I had a client say that she hadn’t been raped because she didn’t scream and he used protection. We must change the narrative of what rape looks like in our society. We have to educate our youth in all things concerning sex, not just the parts that are comfortable to discuss. Then and only then can we begin to end the cycle of teen dating violence and sexual violence.



Leontyne Evans works as the survivor engagement specialist for Survivors Rising, where she helps to empower and uplift survivors by providing education and resources that encourage survivor voice and self-sufficiency. She is a published author of two books, Princeton Pike Road and Relationships, Friendships and Situationships: 90 Days of Inspiration to Keep Your Ships From Sinking, both of which support her mission of ending the cycle of unhealthy relationships. 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.

The sensitivity of boundary setting in collectivist cultures

By Shabnam Brady October 11, 2021

In our Westernized culture, we are prone to upholding a dominant approach to managing our relationships that involves boundary setting. Thus, our therapy practices and culture often emphasize setting boundaries as a key element of developing and maintaining “healthy” relationships. The United States mostly engages in an individualistic culture, which can promote and help to sustain boundaries to protect and even nurture a relationship with the self. 

But what about cultures in which the family is at the center and boundaries are often blurred? What is deemed “healthy” in such cultures — and who defines this? These are called collectivist cultures. In collectivist cultures, family members identify closely with one another and often make decisions for the family as a whole rather than for the self. Sacrifice, honor and loyalty are some of the core values of such families and cultures. For example, saying no to the family or setting limits on simple family events or dinners may be perceived as selfish and rude. 

Imagine Maryam, a married mom of two, fatigued from her workweek and yet being asked to host the weekly family dinner. This gathering includes grandparents, uncles, cousins and, of course, mom, dad and siblings. Maryam rushes to the store, then home to cook a very involved rice and stew dish. The family arrives early, adding anxiety to her already-exhausted mental state. 

Later in the week, Maryam attends her therapy session. Her therapist suggests setting limits and saying no to hosting these events in the future or proposing that her sister, Fara, hosts the next time. Maryam agrees, but she struggles because this would mean making a decision for herself and based solely on her own needs. Although this may be considered “healthy” by the dominant culture, it is causing Maryam more stress and, now, added guilt. Maryam may not even feel comfortable sharing these new thoughts with her therapist due to her culture of origin’s boundary for respecting authority (she may potentially view the therapist as the expert and authority). 

Workable boundaries

What do we do, as mental health providers, in the case of Maryam? 

First, we can validate and normalize her emotions. Next, we may pose questions to allow her to further express herself and ponder potential resolutions. In talking with her, we may at some point realize that she is stressed but at the same time happy to see and host her family. There may be no need for behavioral change here; rather, expressing emotions in a safe place and feeling heard by the counselor may be enough for Maryam. Potentially, she may need support identifying her emotions to further express them too. 

If Maryam continues to share concerns about her fatigue level, it may be supportive to suggest what I call a “workable boundary,” with consideration given to her culture and her values. This workable boundary could simply be adjusting the time that everyone comes over so that Maryam has some time to rest first upon arriving home. 

A workable boundary is flexible. It is not rigid like typical boundaries may be perceived or promoted to be. It is similar to a compromise and works to respect the client’s culture of origin and needs. The flexibility may prioritize the client’s culture and empower the client to choose what is workable. 

Straying away from the stringency of a black-and-white approach to boundary setting can be more inclusive. The less we guilt individuals into self-care and self-prioritization, the more we can become aware of their needs, wants, values and cultures. Some individuals in collectivist cultures gain energy, pride, strength and honor when the family is well and happy. 

Prioritizing client boundaries

The connectivity of emotions, identity and well-being in a collectivist family and culture of origin is complex, requiring respect for exceptional and unique boundaries. Roles and authority may serve a special function in the collectivist family experience. 

For example, in my own personal collectivist family experience, as well as in working as a counselor with college and high school students with collectivist cultural backgrounds, I learned that even the majors we chose for our college experiences originated in our family values and expectations. We honored our families by choosing to become accountants, doctors and engineers, among other professions. We struggled and wanted to quit. Yet many of us continued on this path to a field mostly chosen for us by the influence of our collectivist cultures and families. 

Experts on setting boundaries may advise students who are feeling stressed to follow their own career paths, which would encourage straying from the family norm. Here is an opportunity for us to remember our counselor ethics and to prioritize client values over our own and even over those of the dominant culture here in the United States. We can work to be culturally humble and learn to navigate and negotiate values as clients desire to apply them in their own lives. 

The goal of the client seeking counseling at the university counseling center may simply be to feel humbly supported through their time of feeling stuck or yearning to change majors. Their desire may purely be to not feel alone. What seems simple may be forgotten because we are often inundated by the dominant cultural norm of pursuing our own dreams and goals first. While students and clients may report feeling pressure, they may also report feeling pride in their struggles and motivated in their pursuit of this family dream, especially if they are from collectivist, immigrant backgrounds. 

Likewise, choosing whom to marry may be a family-based decision in collectivist cultures. Boundaries may be perceived as vague. Those outside of these families and cultures may view these family roles and relationships as examples of unhealthy enmeshment. Nevertheless, in some cultures, honoring the family will continue to be the foremost concern when making such a major decision. After all, a romantic partner is commonly considered a new member of the family. Thus, the decision requires the approval of the family in these cultures. 

Providing counseling to an individual who is navigating such circumstances and decisions may require offering further values assessment to support the decision-making process. If family is the client’s No. 1 value, this could support the client’s decision to involve the family in choosing a life partner. Setting boundaries prematurely based on individualistic cultural norms may prevent family members from playing their traditional roles in the individual’s life. 

What may be challenging to understand in the dominant culture — including the high value placed on duty, honor and authority — is part of the traditional fabric in some collectivist cultures. Often, we assume that it is harmful for others to choose our life partners. However, in many cultures, this is viewed as the practice of respecting authority and feeling honored to receive this input and potential blessing. Some clients feel excited to enter these life partner journeys with the support and input of their parents and families. Other clients may not, and that is OK too. The purpose of viewing boundary setting from a wider, more culturally inclusive lens is to stop making assumptions about what is “healthy” for all clients and desired by all clients and to stop promoting only the dominant culture’s perspective of boundaries. 

A nonassumptive approach can lead to greater appreciation of the client’s worldview, needs and ability to reach decisions with the support of the therapist. Open-minded, nondominant cultural perspectives can further encourage this process. Taking such steps can also lead to less guilt, potential shame and frustration on the part of clients who experience the world as bicultural (i.e., negotiating and identifying with two cultures). 

It is often more convenient to go along with the dominant culture’s expectations. Likewise, there is frequently less judgment when choosing the dominant culture’s norms. However, this can be harmful for individuals who appreciate and potentially want to choose collectivist cultural values and norms in some life areas. The pressure many may feel in such situations can be overwhelming. For example: wanting to live at home beyond the age of 18, wanting to date someone chosen by one’s parents, wanting to name one’s child with a chosen family name. 

These are just a few examples of the many decisions children and adults who are bicultural may face (and prefer to make) that others can regard as boundary “blurring.” The therapy setting can provide an open, safe space for clients to explore and arrive at decisions that are best for them, taking all cultures involved into consideration rather than focusing only on the expectations of the dominant culture. Counselors can set aside the boundary-setting trend that might seem liberating on the surface but that may in fact be confusing for some individuals from these cultural backgrounds. By diminishing the idea that inflexible boundary setting is the “healthy” option when it comes to managing interpersonal relationships and life decisions, the lifestyles and complexities that many culturally diverse individuals and families experience and prefer can be included and explored.

Sumala Chidchoi/

Culturally inclusive practices

I am a bicultural, immigrant American therapist and individual who has experienced and navigated, both personally and in session, the guilt that can arise from the boundary-setting expectations of the dominant culture. In choosing my life partner, I practiced strict boundary setting with family members in my collectivist culture. In choosing to go to graduate school to earn a doctorate, the boundaries were workable, blurred and, at times, enmeshed with my family’s dreams and goals. 

I have supported many diverse clients in navigating different areas of life, including grieving differently than their family, by using workable boundaries that include both their cultural and individual needs. The following steps can support more culturally inclusive practices for navigating boundary setting in collectivist cultures. 

>> Develop and pose questions or prompts that reduce the potential for “dominant culture speak,” such as “your needs” and even the word “boundary.” Instead, consider adding to your language the phrases “cultural considerations” and “family needs tied to your needs and wants.” For example, a possible question to explore with the client is, “I hear that’s hard for you. What are some ways you can meet your family needs that perhaps seem to influence your needs, especially with the weekly family dinners?” 

>> Explore the topic of guilt with clients. How does guilt affect them interpersonally and emotionally? Does it apply in their identity, role and cultures? How, if it all, does guilt come up when considering boundaries with family members, partners or friends? 

>> Investigate what the word “boundary” means to the client. Does it have a meaning? Is it culturally relevant for them or is it a new concept? How would they like to incorporate it into their wellness journey, if at all? 

>> Offer psychoeducation on boundary-setting practices for potential emotional wellness while acknowledging cultural implications. Then ask for feedback and reactions. What does the client think of this concept? Do they agree or disagree? Why? Would they like to explore these practices in their life? 

>> Finally, individualize boundary-setting practices to respect the client’s culture, needs and wants. Assess what these practices are and introduce concepts such as workable boundaries or more innovative ways that may work for the client in an inclusive style. Implement a feedback model in therapy to assess the client’s satisfaction level with such strategies.



Shabnam Brady holds a doctorate in counseling psychology. She is a therapist, professor, author and founder of Therapy for Immigrants (@therapyforimmigrants), an Instagram community whose aim is to raise awareness and expand inclusivity practices in mental health for immigrant communities. Contact her at


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