Monthly Archives: March 2022

The impact of legalized marijuana on professional counseling

By Bethany Bray March 30, 2022

In 1996, California voters passed Proposition 215, making the Golden State the first in the U.S. to legalize the use of medical marijuana.

Two decades later, the medical use of cannabis is legal in 37 states, Washington, D.C., and the territories of Guam, Puerto Rico and the U.S. Virgin Islands. Additionally, 18 states, Washington, D.C., and two territories have enacted legislation to regulate cannabis for nonmedical (i.e., recreational) uses, according to the National Conference of State Legislatures. Just three states — Kansas, Nebraska and Idaho — do not allow public access to cannabis in any form, medical or otherwise.

In states where cannabis use has been legalized, many medical and mental health practitioners have found it necessary to shift their mindset — from viewing marijuana as an illegal substance to something that medical doctors can condone or even recommend and that potentially has benefits for a range of conditions, including chronic pain and posttraumatic stress disorder (PTSD).

“When it was first becoming legalized, it was a bit of a panic for the [addictions] treatment community around ‘How are we going to deal with this?’ What has evolved is that now, it’s viewed in a similar way as alcohol is: There is a continuum of users, [and] it can be abused but also used socially or occasionally,” says Adrianne Trogden, a licensed professional counselor and supervisor (LPC-S) and licensed addiction counselor (LAC) with a private practice in New Orleans. “It’s a hard transition for treatment providers to go from thinking of it as an illegal street drug to being dispensed as a medicinal medication. … In treatment facilities, you see the worst of the worst — those whose lives have been ruined by substance. It’s easy to see the ugly side of addiction and naturally be leery of [marijuana] being used for medicinal use. That mindset is hard to shift.”

Legalization has also meant that professional counselors cannot keep their heads in the sand about this issue, regardless of how they feel personally about the use of marijuana, says Paula Britton, a licensed professional clinical counselor and supervisor with a private practice in Cleveland. Practitioners need to be comfortable broaching the subject of how and why a client uses marijuana, and they should be familiar with the pros and cons of the substance as it relates to adult mental health and wellness. In addition, they should understand the nuances of cannabis regulation in their state.

At the same time, counselors must know how to assess clients for cannabis use disorder and listen for indicators that an individual may be drug seeking, Britton says.

Talking about clients’ marijuana use “gets tricky,” admits Britton, who is licensed as both a counselor and a psychologist. “Because of that, many counselors don’t want to get involved or learn about it. But I don’t know if we’re going to have that option in the years to come” as it becomes increasingly legalized. “We have to be aware that this is going on and that [marijuana use] is helpful for some people,” she continues. “We have to acknowledge that our clients are using it, or wanting to use it, for medical or recreational purposes and [consider] what … that mean[s] for us in counseling.”

Mixed messages

Cannabis is classified as a Schedule 1 substance under the Controlled Substances Act, which makes its distribution a federal offense. This puts marijuana alongside heroin, ecstasy, LSD and other substances that are “defined as drugs with no currently accepted medical use and a high potential for abuse,” according to the U.S. Drug Enforcement Administration.

This sends a confusing and mixed message, both to the public and to health professionals, given that marijuana may be legal and OK to use at the state level yet illegal federally, Britton says. In addition, the complicated regulatory scheme has impeded much-needed research on the effects marijuana can have on a range of conditions when used in a controlled, medically sanctioned way.

In the meantime, counselors must rely on the limited research that has been done by other disciplines or by researchers outside of the country. The few studies that have been done have yielded mixed results on marijuana’s efficacy for mental health diagnoses, particularly anxiety and depression, Britton notes.

“There’s just so much we don’t know,” says Britton, a professor of clinical mental health counseling at John Carroll University. “If we [counselors] are going to be evidence based, it’s hard to have an informed decision about what you think without that [research] behind you.”

One example of the mixed messaging surrounding cannabis use involves the U.S. Department of Veterans Affairs (VA). The VA has done studies that show medical marijuana can help individuals with PTSD, yet it will not endorse its use for VA patients because of the federal law, Britton notes.

The American Psychiatric Association issued a position statement in 2019 saying that it would not endorse the use of medical cannabis for the treatment of PTSD “because of the lack of any credible studies demonstrating [its] clinical effectiveness.”

Aaron Norton, a licensed mental health counselor, licensed marriage and family therapist and certified rehabilitation counselor with a private practice in Largo, Florida, suggests that the mixed data regarding marijuana use allows people who argue either for or against its legalization to cherry-pick studies that support their view. Some people, for example, have cited reports linking the legalization of medicinal cannabis with lower opioid overdose mortality rates as evidence that medical marijuana is the answer to ending America’s opioid epidemic.

“What I am concerned about is the touting of medical cannabis as the cure-all magical wonder drug,” says Norton, who has written and presented on legalized marijuana’s impact on the counseling profession. “There is contradictory evidence out there … [and] overall there’s very little evidence that medical marijuana helps many of the things that we think it does. I’m concerned about the claims that are made and [the] use of it in mental health treatment.”

It is well-known, however, that marijuana use can have a negative impact on child and adolescent brain development and has also been tied to lung problems (when used in inhaled forms) and other challenges later in life, Britton says. She advises counselors to also be mindful that marijuana use can affect the efficacy of psychotropic medications such as antidepressants that are commonly used by clients.

Even when used legally, marijuana can still have adverse effects on clients’ employment, particularly if they work for the federal government or in fields that require regular drug testing. Marijuana stays in the human body and can show up on drug tests weeks after a person uses it, notes Britton, who co-authored a recent Journal of Counselor Practice article on Ohio mental health professionals’ attitudes, knowledge and experience regarding medical marijuana.

This aspect of marijuana use also has implications for counselors who work in the field of substance use because it can be difficult to determine an individual’s length of abstinence, says Trogden, an assistant professor in the counseling department at the University of the Cumberlands.

Dosing concerns

Dosing is another potential area of confusion related to legalized marijuana for individual users and health professionals.

Norton says that in Florida, it is mostly left up to the individual to purchase and use whatever dose they believe is best — a situation he labels a “free-for-all.” Physicians in Florida do not prescribe specific doses to patients who are granted a medical marijuana card because it remains illegal federally, he explains.

Similarly, Britton points out that employees at marijuana dispensaries in Ohio are not doctors and will often sell customers whatever dosing amount they request. Determining the correct cannabis dosing is complicated because the “optimal dose” will be different for every person, she says. The same amount of substance will affect people differently depending on whether it is inhaled or eaten, such as in gummy candy or baked goods.

Matthew McClain, a school counselor in Fort Morgan, a small town in northeast Colorado, notes that dosing is a concern for youth because they often won’t read or adhere to the instructions or labeling for items that have come from a cannabis dispensary. For example, a teenager may open a marijuana brownie or piece of cake and eat the entire thing without pausing to read or acknowledge that it may be equal to two or three servings. “That can be pretty significant for the [body] systems of a teen,” says McClain, the executive director of the Colorado School Counselor Association (CSCA).

School counselors in Colorado are finding that youth (mostly in middle or high school settings) have adopted more casual attitudes about marijuana since its legalization in the state, McClain notes. In recent years, he says, school counselors’ awareness and concerns have shifted from students smoking marijuana to their consumption of it via vaping or edibles, both of which feature a high concentration of tetrahydrocannabinol (THC), the component in marijuana that produces a high. These methods allow students to consume the substance in a more clandestine way than smoking does, including during the school day. Edibles such as candy or gummy bears also make exposure and consumption of marijuana more familiar and less foreboding to youth.

One way to counteract this issue is to train teachers and noncounseling school staff in mental health first aid, McClain says. This can better prepare school staff members to notice behavior changes and other indicators that a student might benefit from talking with a school counselor — about marijuana use or anything else, McClain says. CSCA also offers regular trainings and continuing education programming to its members on marijuana use and its effects in school settings, he adds.

“This just adds another layer of complexity to the job, one other thing that can be going on” with students, McClain says. “We [at CSCA] have made sure that we’ve provided [educational] opportunities by seeking out experts and people who are well-versed to provide information and training, and other states are in a similar situation. We may want to stick our heads in the sand, but at the same time, if we’re dealing with the day-to-day lives of our kids, we want to make sure we can provide help and support.”

Use as instructed?

Norton says that in his experience, only a small fraction of his clients who have medical marijuana cards use the substance for medical reasons. He believes the majority obtained a medical marijuana card so they could use it recreationally, which remains illegal in Florida, or because they have cannabis use disorder.

When asked, many of these clients are unable to tell Norton why they have a medical marijuana card, or they name conditions — such as headaches, attention-deficit/hyperactivity disorder and trouble sleeping — that aren’t listed on the state statute that allows for the use of medical marijuana. The only mental health diagnosis mentioned in Florida’s statute is PTSD, Norton says. However, there is language in the law that allows medical marijuana to be prescribed for “similar” conditions to those listed in the statute, which gives physicians flexibility. Norton says he has never heard of a client who has been turned down for a medical marijuana card.

“Even clients who perceive they are using it medically … judge its efficacy by [not only] if they feel better but also [if they] feel high or euphoric — and that’s not the point of medicine,” says Norton, the executive director of the National Board of Forensic Evaluators and an adjunct instructor at the University of South Florida’s rehabilitation and mental health counseling program. “People are using cannabis to feel better in the moment — sleep better, lessen anxiety, etc. — but at the expense of addressing their core problems, which are thoughts and behaviors. They’re missing the opportunity for recovery from their behaviors.”

Trogden agrees, saying, “The challenge, just as with any other medication, is that you really need therapy and counseling services to gain insights and awareness [about a presenting issue] along with taking the medication.” She adds that in her experience, medical marijuana has benefited clients who have depression or other mood disorders, trouble sleeping, anxiety, racing thoughts or a history of trauma. But Trogden also notes that in addition to its potential benefits, marijuana use can cause paranoia or lead individuals to use it as a “crutch” to cope with pain and other difficult feelings.

Britton has done research on medical marijuana and counseled clients who use it. She says the substance can be tied to symptom relief or otherwise benefit individuals who have chronic pain, sleeping difficulties, autism spectrum disorders, anxiety and hyperarousal, nausea (such as in those undergoing chemotherapy treatment for cancer) and a range of other issues. At the same time, she says that more research is needed.

In Britton’s experience, medical marijuana has helped some of her clients, while others did not reap any benefit — or even had negative outcomes — from its use. “And that’s consistent with the literature,” she notes. “Not everyone benefits. It’s not a miracle cure. But just like with antidepressants [and other psychotropic medications], it can soften a client’s symptoms … [so they can] do the therapeutic work. But they still need behavioral intervention.”

Now that marijuana is legal in most states, the counselors interviewed for this article agree that clinicians should include specific, detailed questions about its use during the client intake process. Asking clients how often and why they use marijuana can help practitioners better understand the context of their use and assess for dependence or cannabis use disorder.

Cannabis use disorder is characterized by behaviors that indicate that a person cannot stop using the substance even though it is causing the person social or health problems, such as overusing or craving marijuana or driving while impaired. According to the Centers for Disease Control and Prevention, individuals who use cannabis frequently or began using it in adolescence are at greater risk of developing this disorder.

Practitioners should embed questions into assessment about how much and how often clients use marijuana, similar to the way they would ask about clients’ consumption of alcohol, suggests Trogden, who teaches in an addiction counseling training program for the state of Louisiana and is the chief operating officer of a behavioral health organization in New Orleans.

“We should be assessing for a variety of things. It’s helpful to understand the whole person and get a holistic understanding of what’s going on. Substances would be a part of asking about medication, whether it’s blood pressure [medication], mental health medication or marijuana,” Trogden says. “It’s important to call it out specifically, [asking] ‘Do you use marijuana?’ If you just ask, ‘Do you use drugs?’ they’ll probably say ‘no.’”

Trogden says multiple clients have mentioned to her in later counseling sessions that they smoke marijuana after initially answering “no” to generalized substance use questions at assessment. As a result, she’s learned to ask specifically about marijuana in assessment because some clients do not consider it to be a drug or on the same level as illegal substances.

Britton suggests that counselors take a nonjudgmental, curious and respectful approach to marijuana assessment with clients. “If a client senses that you are going to judge them — on any topic — they’re probably not going to tell you,” she says. “Start thinking differently about how you ask [and] how you put it on intake forms. Get outside of judgment.”

When clients ask

Clinicians in states where marijuana is legalized may have clients ask whether it could help them with symptoms related to their presenting concern or mental illness. Counselors cannot prescribe medication, however, and making a recommendation or giving guidance on marijuana use — or any other kind of health regimen — goes beyond a counselor’s scope of practice, says Emily St. Amant, counseling resources and continuing education specialist for the American Counseling Association. She recommends that counselors refer to the 2014 ACA Code of Ethics, particularly Standard C.2.a.

St. Amant, a licensed professional counselor with a mental health services provider designation in Tennessee, urges counselors to respond to client questions about legalized marijuana use with a nonjudgmental attitude and a recommendation to speak with a licensed psychiatric medical provider about the topic.

“I would also provide education about why I’m making that recommendation: my own scope of practice [and how a prescriber is qualified] to discuss risks and benefits, side effects, drug interactions, etc.,” says St. Amant, whose background is in substance use counseling. “As a counselor, I need to ensure I’m staying within my scope of practice or what I’m personally licensed to do. We open ourselves up for liability and ethical violations when we drift out of our lane and into the lane of other areas of expertise. We also open ourselves up for potentially harming our clients if we impose our own values or ideas on them. That takes away their autonomy, can damage the therapeutic relationship and creates a power imbalance.”

Rather than offering advice to clients regarding legal marijuana use, counselors should focus on strengthening clients’ personal autonomy and decision-making skills, St. Amant emphasizes. Ultimately, it is the client, not the counselor, who must make and live with the decision to use (or not use) marijuana, medicinally or recreationally.

“That doesn’t mean we leave them hanging and avoid helping in some way. That would be risking invalidating the client’s concern and a missed opportunity to be supportive,” St. Amant says. “We can help our clients by providing education, teaching problem-solving skills, eliciting their decision-making process, validating their concerns and promoting their empowerment and autonomy. … Even for us experienced counselors, it’s vital to ensure we are staying true to the fundamentals of client-centered principles. Those that are particularly relevant here include the fact that clients are the experts in their own lives and that we genuinely trust that they can decide what’s best for them.”

Decision-making

Talking about a client’s marijuana use in counseling sessions will have a very different dynamic depending on whether the individual is voluntarily pursuing treatment or has been mandated to complete therapy, often as the outcome of a court case.

In the second scenario, practitioners must remember — and explain to the client — that their work goes beyond the needs of the individual client, Norton says. The client may want to get their driver’s license returned after a DUI violation, for example, and this is contingent on completing a regimen of counseling sessions.

“The counselor is responsible not only for the safety of their client but [also for] the safety of the public,” Norton says. “You have to address the issue [of their marijuana use]. You can’t ethically clear them if they’re just as unsafe now [at the conclusion of therapy] as when they first came to you. Counselors now have more than one stakeholder in what you do.”

Norton is a counselor supervisor, and his interns often work with clients who are mandated to complete counseling after a DUI or whose children have been removed from their care by child protective services because of their marijuana use and related behaviors. Norton also sees similar scenarios in the work he does as a substance use and DUI evaluator for the court system in Florida.

It is common for clients to try to skirt the sobriety requirements in mandated treatment situations by obtaining a medical marijuana card, according to Norton. This scenario puts the counselor in a no-win situation because the client has a way to legally obtain marijuana and continue their behaviors, he says. Addressing the root of the problem that brought the client into counseling becomes exponentially harder because the counselor is not a medical professional and cannot advise the client to stop a medically prescribed treatment, Norton points out.

Norton’s experience — and frustration — with this scenario led him to create a decision-making matrix (see below) for counselors to use when discussing marijuana use with clients who have been prescribed legal cannabis for medical use.

When addressing marijuana use in counseling sessions, Norton suggests that practitioners focus on clients’ motivation to change and their attitudes toward stopping their use of marijuana. His model offers different treatment scenarios for clients who have and have not been diagnosed with a substance use disorder and for situations in which the counselor has leverage (i.e., resources or outcomes the client wants, such as the return of a driver’s license or child custody, that are conditional to successful treatment completion).

In the case of clients who want to stop using cannabis, the counselor can collaborate with and refer them to a physician to find an alternative treatment. For those who do not want to stop using cannabis, the counselor can take a harm reduction approach to make gains toward behavior change in other ways, Norton explains. This includes strategies such as using motivational interviewing to explore the client’s thoughts on continuing their marijuana use or co-creating a “preventative strategy plan” with the client to identify benchmarks such as avoiding driving while using cannabis.

A harm reduction approach can prompt growth and behavior change in clients even while they continue to use cannabis — and much more so than simply leaving it unaddressed, Norton emphasizes.

Taking a nonconfrontational and supportive approach

Many of the harm reduction techniques Norton includes in his decision-making matrix involve collaboration between the counselor and the client. This ensures the counselor meets the client where they are, he says, and increases the likelihood of positive behavior change.

Katharine Sperandio, Daniel Gutierrez, Alex Hiller and Shuhui Fan, co-authors of the April 2021 Journal of Addictions & Offender Counseling article “The lived experiences of addiction counselors after marijuana legalization,” interviewed six professional counselors in Washington and Colorado (the first states to legalize marijuana for recreational use) who work with clients experiencing substance use disorders. They found that using a nonconfrontational, “motivational enhancement” approach with clients regarding marijuana use was more beneficial than addressing it head-on.

One participant in the study provided an example of a nonconfrontational approach. They broached clients’ marijuana use by framing it as a question: “Why do you think it’s a problem for you?”

The co-authors also learned that with the legalization of marijuana, practitioners are seeing an increase in client justification and rationalization of marijuana use and less acceptance that it can be harmful or problematic, particularly among adolescents. Many clients were found to be using legal marijuana to numb negative thoughts and emotions, ease chronic pain, cope with trauma and “as a substitute for alcohol or other drugs rather than seeking [counseling] treatment because it was so readily available.”

The study participants also reported that clients were “more likely to walk out of treatment” and less likely to communicate about marijuana use (even if it was a source of other problems) if they felt there was a policy or recommendation to decrease marijuana use.

When school students are facing discipline for marijuana use, addressing it in a supportive way is the best approach to discourage those students from returning to risky behaviors, McClain says. When possible, it is helpful to involve the student and their parent(s) or guardian(s) as well as the school counselor and administrator to ensure that the student has a support system and reentry plan that doesn’t involve marijuana use and related behaviors, he says. Such a plan might include regular check-in conversations with a school counselor.

Taking a holistic approach, rather than only punishing, avoids setting the student up for failure and ensures that all of the student’s stakeholders are on the same page, McClain adds.

“We want to make sure they have a support system, including a counselor, to turn to for help. As much as we can surround them with support, hopefully the outcome will be better,” says McClain, who has worked as a school counselor for 17 years.

Case example

An adult woman came to see Britton for PTSD after experiencing sexual trauma. The client was experiencing intense flashbacks, having trouble sleeping and struggling with chronic pain. Britton surmised that the pain was related to her trauma because the client held her trauma in her body.

Britton used dialectical behavior therapy with the client, who made a small amount of progress in the first year but eventually stalled despite staying engaged in sessions and showing a willingness to try exercise and other actions that Britton suggested. The client continued to be plagued with sleep difficulties and night terrors, even while using a prescription sleep aid. Britton continued to co-treat the client while referring her to a practitioner who specialized in eye movement desensitization and reprocessing (EMDR) therapy.

“It took her a long time to forge trust; it took her several months to even tell me what happened. Once we got to that part, we started making some progress, but then she hit a wall,” Britton recalls. “Not only was the EMDR not helpful, but she [also] found it upsetting and she started going downhill, discouraged that she’d ‘never get better.’ … She felt really stuck and scared, and we weren’t making a whole lot of progress. The more she couldn’t sleep, the worse her symptoms got.”

Avgust Avgustus/Shutterstock.com

Eventually, the client brought up the possibility of trying medical marijuana. Britton responded by saying that she couldn’t advise her on whether it would be effective, but she could write a letter confirming that the client had PTSD in case she wanted to pursue obtaining a medical marijuana card.

Ultimately, the client did receive a medical marijuana card and began using cannabis to alleviate her pain and trauma symptoms.

“It wasn’t a miracle cure. … She still presented with some trauma symptoms [while using medical marijuana], but it helped her sleep, and that was huge,” Britton says. “It didn’t ‘cure’ her, but it took the edge off so she could look at things a little clearer, and she started feeling some hope [after] feeling so deflated, so defeated. It gave her the energy to work toward some other behavioral treatments.

“She wasn’t drug seeking; she was seeking symptom relief. It helped enable her to do the work that was in front of us [and] gave her the braveness to face it. It was just part of [her treatment]. It wasn’t the full answer, but I was glad we tried it.”

Bias management

The counselors interviewed for this article agree that clinicians have a responsibility to seek training, consult with colleagues and stay up to date on the regulations regarding marijuana in their area as well as the ways that its use — and misuse — can affect mental health.

At the same time, counselors are ethically bound to keep their personal views about marijuana (and all substance use) out of their counseling work, St. Amant notes.

“Substance use exists on a spectrum, and just because someone uses legal or illegal substances does not mean they have a substance use disorder,” she says. “Counselors must be careful not to impose their own values about substances use on their clients or project their own beliefs onto others. When the use of substances is conceptualized as a moral concern or a personal failing, we add to the stigma of substance use. Our attitudes must remain nonjudgmental and nonmoralistic when it comes to substances.”

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Can counselors use legalized marijuana?

In states where marijuana use is legal for medicinal or recreational purposes, counselors have the right to use it on their own time, but they also have the ethical obligation to ensure that it does not cause an impairment to their clinical performance and their relationship with their clients. They can do this by approaching it the same way they do with alcohol use.

Counselors can ethically use legal substances as long as they do not perform clinical duties under the influence, the use does not impair their ability to function (e.g., seeing clients while experiencing a hangover or the prolonged impacts of the substance) and they are able to use the substances responsibly (e.g., not driving under the influence). If counselors choose to use legalized marijuana, one should be aware of how long the effects last (which can linger into the next day for marijuana) and ensure that no pictures are posted of them using the substance on social media.

If counselors have difficulty controlling their use or if it affects their health or clinical abilities, they should seek out an evaluation to see if they could benefit from treatment, and they should refrain from providing clinical care until it’s determined that they can do so safely and ethically.

Our ethics are founded upon ensuring client safety and preventing harm to those we serve, so our clients’ right to be protected from potential harm by their counselor using substances supersedes our personal freedom during the time in which we are working with them. Yes, we counselors are adults who are allowed to live our lives how we personally see fit, but, no, our personal choices cannot come at the cost of our clients’ safety.

See Standards C.2.g. and A.1.a. of the 2014 ACA Code of Ethics at counseling.org/ethics.

— Emily St. Amant, counseling resources and continuing education specialist for ACA

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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

Self-diagnosis in a digital world

By Lindsey Phillips March 28, 2022

For better or worse, social media posts about mental health, paired with the ease of Googling one’s own symptoms, are enticing many people to self-diagnose. In fact, a 2021 Vox article, “How mental health became a social media minefield,” asserted that social media is becoming known as the “WebMD for mental health.”

Some clinicians appreciate the self-awareness that can result from social media postings and online searches about mental health, whereas others focus more on the potential harm that self-diagnosis can cause. Counselors need to be aware of the hazards of self-diagnosis, but many in the profession believe they can also use it to gain insights into the inner world of their clients.

Micheline Maalouf, a licensed mental health counselor and owner of Serein Counseling in Orlando, Florida, chooses to focus on what she can learn from a client’s self-diagnosis. In her practice, she has noticed more clients asking if they have a particular mental health disorder because of social media content. Recently, a client told her they thought they might have obsessive-compulsive disorder (OCD). When Maalouf asked why, the client explained, “I saw this TikTok video about signs that you may have OCD. I resonated with some of the symptoms but not all, so I’m not sure if I have it. My situation wasn’t exactly like the person’s in the video, but it got me thinking.”

ImYanis/Shutterstock.com

Maalouf asked more questions about the symptoms from the video that had resonated with the client, and she also educated the client on the process of determining a diagnosis, emphasizing that it is not as simple as matching symptoms from a checklist. Disorders manifest differently for everyone, she told the client, and depend on many factors, including life experiences, gender, race and more. But Maalouf also reassured the client that their awareness about OCD symptoms was “important information … because it could be the first step in figuring out if something is actually going on.”

Maalouf, an American Counseling Association member who specializes in treating anxiety, depression and complex trauma, says she is thankful for conversations such as these for two reasons. First, it means the client has some self-awareness, which is a good thing, she says. And second, it provides her with more insight into her client and the potential issues they need to work on in session — regardless of whether the issues match the client’s self-diagnosis.

Searching for answers

People are hungry for mental health answers, observes Lindsay Fleming, a licensed professional counselor (LPC) with a private practice, Main Street Counseling Solutions, in Park Ridge, Illinois. They want to learn how a potential diagnosis or certain symptoms are affecting their lives and ways to better manage them. What’s hard, she says, is “when someone is doing that by themselves and doesn’t have a professional guiding them” and helping them understand it.

“A lot of people like to have that diagnosis because it explains [what’s happening],” says Tristan Collazo, a licensed resident in counseling at Wholehearted Counseling in Virginia Beach and Carrollton, Virginia. “Some people think it’s stigmatizing, but a lot of people find hope in it because it finally — for once in their life — explains what’s going on.”

Kaileen McMickle, an LPC and founder of Inner Ascent Counseling in Rice Lake, Wisconsin, often works with clients who are struggling with anxiety disorders. She finds the more anxiety a person has, the more likely they are to seek information about what they are experiencing. “It can be hard to feel so isolated and not know what’s going on,” she notes. “People just want certainty. And with Google and social media, it’s so easy to go [online] and try to make sense of what they are experiencing.”

McMickle specializes in treating anxiety, trauma and OCD, and she frequently sees self-diagnosis with clients who have OCD. They often wonder if what they are experiencing is “normal.”

“We all have intrusive thoughts. We all engage in safety behaviors in some way,” McMickle explains, “but OCD can feel a lot different … [and outside] the ‘normal’ range of behaviors,” such as feeling compelled to tap one’s car 10 times before going into a grocery store or spending two hours trying to find “just the right” products. “People want to know what’s happening to them; they want to know what they’re experiencing,” she says.

Collazo says that a couple of his clients initially self-diagnosed because they identified with a particular trait of a disorder. Someone may see a video about how controlling behavior and manipulation are traits of narcissistic personality disorder, for example, and fear that they have the disorder because they engaged in this type of behavior once in a past relationship. They might have been upset and accused their partner of not loving them, for instance. Making such a statement can be a form of manipulation used by someone with narcissistic personality disorder, Collazo notes, but he points out that it is also something many people who don’t have the disorder might blurt out in the heat of the moment.

It is human nature to sometimes relate to a disorder or disease after learning a little bit about it, Collazo says. “We probably all have traits from different personality disorders,” he observes, “but it takes certain criteria to have an official diagnosis, which people don’t often understand. They may have a trait or symptom [from a personality disorder] … but that does not mean they have that disorder.” In his social media posts, Collazo tries to debunk the tendency to self-diagnose based solely on resonating with a particular trait.

That is why it is so important to help clients distinguish between symptoms or traits and an official diagnosis, says Shani Tran, a licensed professional clinical counselor. If a person sees a post about how an inability to sleep, a lack of energy and feelings of sadness are symptoms of depression, they may assume they are depressed because they are struggling with one or more of those symptoms. But having trouble sleeping could be the result of an array of issues, Tran notes, and not necessarily evidence of a mood disorder.

Tran, owner and founder of The Shani Project, a group counseling practice in Minneapolis, attempts to personify anxiety, depression and trauma on her TikTok account as a means of educating others about mental health issues. She has noticed people resonating with some of her mental health “characters” by commenting, “Oh, that’s so me.”

In her online posts, Tran makes a point of saying, “these may be the signs of” rather than “these are the signs of” to underscore that just because someone resonates with a particular trait in one of her videos doesn’t mean that they necessarily have a diagnosable disorder.

For example, someone can experience a trauma and not have posttraumatic stress disorder (PTSD). It often depends on functionality. “Whenever a diagnosis is being made, there has to be an area of the person’s life” — social life, personal life, work or school — “that they aren’t functioning in for it to be a diagnosis,” Tran notes. Even if someone with a mental health issue is high functioning (meaning they function at a higher level than others with the same condition), thereby making it more challenging to determine a diagnosis, there is often a change in the severity or duration of symptoms from how they were functioning before to how they are handling things now, she adds.

Tran hopes her social media content will invite conversations about mental health and get people who relate to some of the symptoms she highlights to consider talking to a mental health professional. Her book Dope Therapy: A Radical Guide to Owning Your Therapy Journey, which she wrote to help people navigate therapy from start to finish, will be published this summer.

McMickle observes that “when people self-diagnose, they are looking for information about themselves, and that can be a really helpful, positive thing. That might mean they’re experiencing some discomfort or emotional dysregulation and they want to change that.” But given the potential for misinformation online, she also cautions counselors to ask clients where they are getting their knowledge of symptoms and disorders and to be careful about any resources — especially social media accounts — that they provide to clients.

Potential dangers

As counselors know, accurately diagnosing mental health conditions is complex, requiring years of education and training to truly understand the nuances. Social media, however, tends to simplify this process and often reduces psychological theories or disorders into brief snippets or common stereotypes. For example, a social media post might boil diagnosis down to “Signs you are with a narcissist” or “Things you didn’t realize were ADHD.” Or a meme may depict someone with “avoidant attachment” agonizing over their choice of either cutting someone out of their life or clinging to the person so the person won’t abandon them.

These types of posts don’t address the complexity of mental health issues or any new research on the topic, such as how attachment is a pattern and not a fixed state, says Ilyse Kennedy, an LPC and licensed marriage and family therapist. “So, people may think certain things about themselves or may resonate with something without having all the nuisance behind it of what that actually means,” she says. Kennedy notes that it has taken her years of studying attachment disorder and reading several books before understanding her own attachment style.

Some clients who self-diagnose come to counseling wanting to receive that same diagnosis from a professional, but people don’t necessarily think about how certain diagnoses could affect them long term, Tran says. For example, some diagnoses could alter the type of life insurance policy someone can get or hinder their ability to obtain security clearances for their job, she points out. Understanding the potential long-term implications makes her careful and cautious when diagnosing clients, she says.

Tran reframes clients’ attempts at self-diagnosis to emphasize their symptoms. If someone asserts that they have depression, for instance, because they are having trouble sleeping and don’t have much energy, she focuses on those symptoms, which could be because of depression or because of anxiety, PTSD or just daily stressors. “People come to therapy looking for answers, but [therapy] is actually very informational,” Tran says. She spends substantial time asking questions and gathering more information about clients: “Tell me more about this low energy. Is it when you wake up? Does it happen at social functions or when you are doing schoolwork?”

Another problem is that anyone, regardless of their qualifications (or lack thereof), can post what might be interpreted as “expert advice” on mental health issues online, which can lead to widespread misinformation. Even people who are well-intentioned can misread or misunderstand mental health information and portray it inaccurately online, causing others who are simply looking for answers to be misled, says Fleming, an ACA member who specializes in attention-deficit/hyperactivity disorder (ADHD).

Social media algorithms, which filter content based on people’s interactions, can also play a role in leading someone toward an incorrect self-diagnosis. The first thing people see when they open up TikTok is the platform’s feed of recommended videos, called the For You page. If someone resonates with a TikTok video about ADHD, for example, and they “like” it, then their For You page begins to show them more ADHD videos. This creates a type of self-fulfilling prophecy, Fleming says, because the person begins to feel that they are “meant” to see the videos.

According to Collazo, this misinformation has the potential to create a nocebo effect — someone develops certain negative or harmful side effects or symptoms because they believe or expect that they will occur. In other words, a social media post saying that people with these particular symptoms have a particular disorder could cause someone to feel that they do, in fact, have the disorder or cause them to engage in behaviors that confirm it.

Given the potential for error when it comes to self-diagnosis, McMickle explores what that particular self-diagnosis means to the client and how it affects the way they view themselves or approach certain situations. Learning about a diagnosis online has the potential to reduce the stigma around it and instill hope in the person that they too can get help, McMickle notes. But if they are self-diagnosing without also seeking professional assistance, or if they are misdiagnosing themselves, then they are potentially stuck in a difficult place and not getting the help they need, she says.

Potential benefits

On a positive front, social media can foster a sense of community and belonging for those who are looking for mental health answers. Discovering online videos and communities of other people who share similar symptoms and struggles, especially for stigmatizing diagnoses such as bipolar disorder, can be rewarding and encouraging, says Kennedy, founder of the group practice Moving Parts Psychotherapy in Austin, Texas.

People typically have a general idea about anxiety and depression, but Kennedy says social media has opened the door for more discussions about trauma and neurodivergence, including diagnoses such as autism and OCD that have often been highly stigmatized.

Kennedy, who specializes in trauma work and individuals with trauma related to dissociative disorders, recalls that when she was first making her professional website eight years ago, colleagues advised her against mentioning trauma because it was a “complex term” and people wouldn’t understand it. Fast-forward to today, and that advice seems ludicrous because there is so much more awareness around trauma.

One of the biggest benefits to the rise in self-diagnosis, at least when prospective clients follow up and seek professional help, is that it provides counselors with insight into the client’s inner world and how they perceive their experiences, Kennedy says. She notes that she has experienced more female clients resonating with social media content on ADHD lately in part because people are just beginning to highlight how the diagnosis can look different in women than in men. When clients tell Kennedy they think they have ADHD, she can use their self-diagnosis to help them reframe how they view their experiences. These clients can then consider their difficulty starting tasks through the lens of neurodivergence rather than as an inherent flaw within themselves.

“Self-diagnosing [online and through social media] can help people identify how they feel and what they’re struggling with,” Fleming says. “It can also be the only place people have access to mental health information.”

From her perspective, client self-diagnosis can provide more context, and the more information she has about the client, the more likely she will be able to help them. A self-diagnosis of ADHD, for instance, gives her the opportunity to ask about when and why the client feels distracted. Are they bored and having trouble focusing, or are they anxious about all they have to do later that day?

McMickle finds that with OCD, the more insight clients have, the better the outcomes. If they realize on their own that they might be experiencing compulsions, obsessions or intrusive thoughts that are interfering with their quality of life, then they may come to counseling more prepared to make changes to improve their situation, she says.

Online mental health searches can be a slippery slope, however, McMickle warns. People can find useful information about what they are experiencing, she says, but they can also “go down a giant rabbit hole with any disorder or any medical problem” and get lost in the possibilities of what is happening to them. There is a difference between being genuinely curious and wondering “Do I have this disorder?” and ruminating about all the ways that a diagnosis is affecting your life, she stresses. That’s why it is important for counselors to do a thorough assessment and figure out where clients are getting their information and how it affects the way they view themselves and their world, she says.

The need for validation

Counselors must be tactful when reacting to a client’s self-diagnosis, always keeping in mind how much courage it takes to seek help, even if the self-diagnosis proves to be off base. Counselors who don’t handle this situation well risk making clients feel invalidated and turn away from getting the help they need.

Validation with self-diagnosis is crucial, Collazo stresses, because it’s likely that other people in the client’s life have told them that their symptoms or potential diagnosis is “just in their head” or that they “just need to put a smile on it.” Therapy is the one place where they can finally hear someone reaffirm that they are not “sad for no reason” and they are
not “broken.”

Collazo first listens and validates clients’ thoughts and feelings about a potential self-diagnosis. Then he explains about diagnostic criteria and, depending on the client’s needs, offers to do a formal assessment. “If their self-diagnosis was right, then great,” says Collazo, “but if not, then counselors [can] offer hope; they can still help the client” get better.

McMickle also errs on the side of validating clients who come in with a self-diagnosis, even while exploring their symptoms further. If a client states that they have had a panic attack, for example, then McMickle would acknowledge that they’ve experienced some type of pain or discomfort (regardless of whether the occurrence was an actual panic attack). She would also ask about the context surrounding the assumed panic attack, any other symptoms the client is experiencing and what the client knows about panic attacks from online or social media.

Learning how to navigate a client’s self-diagnosis without invalidating the client is a crucial skill, McMickle says, because the therapeutic relationship is the cornerstone of effective counseling. “No matter what clients come in with — right or wrong, accurate or not — they’re coming in [to] a really vulnerable space,” she says. “It’s so important that we are really understanding and sitting with them and holding space for them so they can continue talking about things that are upsetting to them and come back for better assessments.”

Collazo acknowledges that it can be difficult to balance validating with assessing the accuracy of someone’s self-diagnosis. He finds that asking questions and remaining curious are good approaches to learning more about what the client is experiencing while maintaining a healthy therapeutic relationship.

Kennedy also relies on questions to discover more about the self-diagnosis. She may ask a client, “What does it means for you to have that diagnosis? Why does it feel important to have it? Does it help you better understand yourself or better learn coping tools? Does it give validation to your pain?”

Even if clinicians disagree with a client’s self-diagnosis, they can still validate the client’s feelings, Tran asserts. If a client says, “I’m feeling sad, and I think I have depression,” she rephrases the statement by saying, “So, what I’m hearing is you are feeling sad. Can you tell me more about that?” This language allows her to clarify what the client is experiencing and provides her with more insight.

The need for a safe space

Recently, after TikTok videos about Tourette syndrome went viral, doctors started noticing an increase in teenage girls who were suddenly experiencing verbal and motor tics. Tourette syndrome tics are unique to each person, so when doctors from different geographical regions observed similarities in the girls’ tics, they started to suspect that social media was playing a role. However, the evidence was anecdotal and overlooked other contributing factors (such as anxiety and stress). Others fear that blaming social media could further stigmatize Tourette syndrome, especially for young women, making it harder for people to disclose symptoms
to professionals.

Likewise, counselors sometimes forget how difficult it is for people to ask for help, Fleming says. By the time someone calls or is sitting in the counselor’s office, they have typically invested a lot of thought and energy in making that decision.

Fleming cautions counselors to avoid hinting at any negative reaction they might have to a client’s self-diagnosis. They should refrain, for example, from saying, “Oh, everyone has that diagnosis on TikTok.” Reacting in disbelief or dismissal could be harmful to the client.

To make it easier for clients to disclose potential diagnoses or symptoms that resonate with them, Fleming invites clients to text her anything they might be hesitant to mention in session, such as their eating habits or a potential self-diagnosis of an eating disorder. She doesn’t respond to the text, but at some point during the next session, she says, “You texted me that you wanted me to check in about your eating habits. How’s that been going for you this week?” If the client still doesn’t want to talk about it, Fleming doesn’t push it any further in the moment but makes a note to try again in a future session. The important thing is for counselors to give clients a safe space to bring things up so they can address it when they’re ready, she says.

Counselors also must be aware of their own preconceptions and stereotypes about certain disorders. Kennedy has noticed that some clinicians may be quick to dismiss a self-diagnosis of bipolar disorder, for instance, because the client exhibits healthy boundaries. Because of stereotypes, even some counselors may incorrectly assume that this isn’t possible for someone with bipolar disorder. Or, if the counselor is fond of the client, they may be hesitant to give the person such a stigmatizing diagnosis.

It is particularly important for clinicians to create a safe, welcoming space for younger clients and avoid dismissing their thoughts and feelings around self-diagnosis. “Adolescents are still trying to figure out who they are, and they sometimes latch on to things that aren’t them” in the process of discovering more about themselves, McMickle says. For example, adolescents often pull away from people, especially their parents, as they form their own identities, but this behavior is similar to traits associated with borderline personality disorder, she notes. So, if they see a video about that disorder, they may worry that they have it and interact with the world as if they do have it.

Kennedy has noticed that with some younger clients, self-diagnosing may be more about needing someone to see their pain or seeking validation from their parents than about being accurate. But it is still important to validate and explore this diagnosis, she emphasizes, even if it doesn’t align with what the counselor is noticing in session.

From self-diagnosis to self-awareness

“Self-diagnosing is giving people more [of an] ability to advocate for themselves and say, ‘No, I think I have this, and this is why,’” Fleming says. “It’s giving people a voice within the professional world.”

It’s also helping to normalize mental health. A few years ago, Fleming often had to reassure clients that it was OK to have anxiety or ADHD. Now she’s having fewer of those discussions because with the increase in self-diagnosis, the stigma around mental health is also lessening.

In addition, social media is helping people develop a sense of self-awareness related to mental health. “People feel less isolated and have a deeper understanding of themselves,” Maalouf says. Many of her TikTok followers leave comments on her mental health videos such as “This explains so much,” “I thought I was the only one” and “This is helpful because now I understand what’s happening with me.” She’s also noticed (based on comments and messages) that this awareness sometimes results in people seeking out counseling to find ways to manage or cope with these issues.

Tran has noted an increase in self-awareness among clients and prospective clients as well. In fact, she considers self-diagnosis to actually be “self-awareness around symptoms.” Before the COVID-19 pandemic and the rise of mental health on TikTok, Tran would get emails from potential clients saying they were looking for a therapist and she sounded like a good fit. Now, she’s noticed the emails are more detailed: “I’ve been struggling with sleep, and I want to have a better relationship with my brother. I’m looking for a therapist with these particular values. Are you able to help me?”

When someone has a general idea of what they are experiencing, they tend to seek out a clinician who specializes in the mental health issue with which they are struggling, McMickle says. This also helps her when she needs to refer someone because it gives her an idea of what type of therapist the person is searching for.

Counselors can make self-diagnosis more of a collaborative process in session rather than viewing it as “dangerous” or “misguided.” If a client comes to Kennedy thinking that they have a certain diagnosis, she goes through the criteria with them and asks what resonates with them. When clients seem to want or need a particular diagnosis assigned to them, she asks about the reasoning behind that. Is it to get accommodations at work or school? Is it to get medication? Is it to have peace of mind and a better understanding of themselves? If clients do need accommodations or medication, Kennedy will recommend a more formal assessment, but if they just want to understand what they are experiencing and find ways to manage it, then she uses their self-diagnosis as a framework to learn more about the client and help them find a treatment plan that works for them.

“When a client comes in with a self-diagnosis, it’s a very brave act,” Kennedy says. “It’s very brave and vulnerable for them to be testing this theory out with you. It’s brave and vulnerable that they’re letting you into their inner world in that way. It can be such a powerful space in the therapeutic relationship to welcome it [the self-diagnosis], even if you don’t quite see it or even if it doesn’t feel ‘right’ for the client. It still allows us to learn so much more about them and to have a moment where we really welcome their vulnerability and create more safety in the therapy room.”

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Read more in an online companion piece to this article, “The rise of counselors on social media.”

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Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@counseling.org.

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

The rise of counselors on social media

By Lindsey Phillips March 25, 2022

Micheline Maalouf, a licensed mental health counselor and owner of Serein Counseling in Orlando, Florida, started making YouTube videos with inspirational and educational messages in 2018, but they weren’t reaching many followers, and making them often consumed a lot of her time. In 2020, her friend suggested she use TikTok, a video-sharing app well-known for its dance challenges, to educate people about mental health. These videos are short, ranging from a few seconds to three minutes, and she worried she wouldn’t be able to provide helpful information in this bite-sized form. But she decided to try it.

Florian Schmetz/Unsplash.com

At first, she created a few fun videos, including one that featured her dancing around her office by herself celebrating a client’s breakthrough. Then she decided to make a short video that introduced herself as a counselor and listed her specialties. That video gained her 120,000 followers overnight.

“From that video, I started getting a lot of questions” about mental health, such as how to manage anxiety or what to do if you have a panic attack, Maalouf recalls. “So, I started generating content based on the questions I was being asked.” That’s when she realized the potential this social media platform offered.

Navigating the unknown

Tristan Collazo, a licensed resident in counseling at Wholehearted Counseling in Virginia Beach and Carrollton, Virginia, was taught in school not to add clients on social media, but newer platforms such as TikTok are changing the rules because counselors don’t have any control over who “follows” them.

To further complicate the matter, some counselors are now getting clients based on their social media posts. Collazo says social media has functioned as a referral source for him because a few of his clients found him through his Instagram or TikTok posts.

This is unfamiliar territory, Collazo notes. Counseling programs “taught us all about boundaries,” he says, “but this is so new that it wasn’t even brought up.”

He constantly talks with his supervisor about how to set boundaries around social media, especially for clients who follow him. From these discussions, he has established some guidelines: He makes social media posts, but that’s where his engagement with his followers (and any possible clients) ends. He doesn’t respond to direct messages. He also includes social media in his disclosure statements and discusses it verbally with clients.

Shani Tran, a licensed professional clinical counselor, suggests counselors add disclaimer statements on the social media content they create. She became overwhelmed with the high volume of comments and questions on her TikTok videos, so she joined a group for therapists on TikTok. Together this group decided to create disclaimers stating their online content is educational and not a replacement for therapy.

Lindsay Fleming, a licensed professional counselor (LPC) with a private practice, Main Street Counseling Solutions, in Park Ridge, Illinois, also creates a clear boundary between her social media presence and her therapeutic one. She gives her clients the option to block her on social media, and she tells them that she will not respond if they do comment on her content and that she will not follow them.

She encourages counselors to make social media a part of the conversation in session. She often asks if clients have seen any of her posts online. If they have, she asks how they feel about the videos they have seen and if any made them feel uncomfortable. This gives them the space to talk and process if needed.

Tran receives daily follower requests based on her social media posts, but many are unaware that they must find a counselor licensed in their state. It’s hard, she says, because she doesn’t like having to turn down someone who needs help. For that reason, she added a link under her profile name that provides her followers with more mental health resources, including ways to find a mental health provider.

She also cautions clinicians against responding to comments or direct messages from people asking for clinical advice about their situation or potential mental health diagnosis. If counselors answer them, they could technically be entering into a therapeutic contract without paperwork, she warns, which is unethical.

Self-disclosing

Social media allows people “to see therapists before they are in the room with them,” says Tran, owner and founder of The Shani Project, a group counseling practice in Minneapolis. “They get to see what content therapists put out, what their voice sounds like when they talk, [and] how they talk about the different specialties. … They get an inside look into the therapists’ own personal lives.”

Allowing others to see the human behind the professional has benefits and potential challenges, so Ilyse Kennedy, an LPC and licensed marriage and family therapist, recommends counselors still maintain healthy boundaries when self-disclosing. But what these boundaries look like can vary from clinician to clinician.

Kennedy, founder of the group practice Moving Parts Psychotherapy in Austin, Texas, shares her own healing journey to normalize therapy, but she’s careful not to overshare to the point clients may worry she’s unable to do her job. For her, posting about having a glass of wine to calm down after a stressful day would cross a professional boundary because it is an unhealthy coping behavior for some. There’s nothing wrong with counselors drinking a glass of wine, she says, but she feels more comfortable sharing other coping strategies such as watching reality television.

Maalouf also discusses her mental health on social media to remind others that “mental health doesn’t discriminate” and to start a conversation on various resources and support systems that can help. Some of her clients have told her that it’s validating to see she’s also working on her own mental health concerns like they are.

But counselors have to be careful with the information they share and how they discuss this with clients, says Maalouf. A client who once saw a video she posted about struggling with depression asked her at the start of the session whether she was OK and able to see her in session that day. Maalouf reassured the client that she is fully present when she comes into work and that she takes mental health days if needed.

Is social media right for me?

Social media allows counselors to humanize the profession, educate others about mental health and even connect people with the resources and services they need. With all these benefits, counselors may find themselves contemplating if they too should create social media accounts.

“Social media is not for everyone,” Maalouf cautions. “There are people that would love it because they enjoy educating and helping people, but then when they get on it, their levels of anxiety go up because they don’t feel safe enough doing it [or] don’t know how to do it appropriately.” She recommends counselors carefully consider the reason and purpose behind why they are joining social media.

“If the purpose is because you love making this type of content or love educating on a large scale, then go for it,” Maalouf says, “and remind yourself why you’re doing it.”

Here are a few tips for counselors who decide they do want to use social media for marketing their business or as a tool to promote or advocate for mental health:

Grab people’s attention. If your content doesn’t capture the audience’s attention quickly, you could lose them, Collazo says. He often uses slogans such as “You are not alone” or “Bet you’ve never heard about this before” within the first few seconds of his videos to engage his followers.
Don’t compare yourself to others. Avoid modeling yourself and your content after others, Maalouf says, and don’t focus on how many followers you have. Instead, focus on your purpose and the goals you want to achieve. She says she’s seen therapists who begin to doubt their own clinical skills because their videos aren’t getting as much attention or doing as well as another clinician’s. “A lot of social media has to do with timing and has nothing to do if you are better than another person,” she notes.
Develop a thick skin. Prepare for negative, hateful comments, Maalouf advises, because you will get them. “You cannot read into those comments and take them personally,” she says. “Remember you’re not going to please everybody.”
Find support. Fleming and Maalouf both recommend counselors find support systems. Maalouf has a group chat with other therapists who are on TikTok and Instagram, and they check in with each other regularly. Fleming consults with other mental health professionals on potential social media content she’s creating to make sure she’s getting her message across in a healthy, educational way. These colleagues can also serve as a source of support if counselors receive hurtful comments or their posts are taken out of context. Fleming once had a video she made about suicide awareness altered by another person so that the audio said, “Go kill yourself.” This was a triggering moment for Fleming, but her online counseling friends reached out and offered support.
Remember, it’s hard work. Creating content and gaining a large following isn’t easy, Trans says. It’s a job that comes with its own stress.

Expanding the reach

Social media, of course, is no replacement for therapy, but more people, especially youth, are turning to these platforms for mental health advice and to share their own mental health struggles. As of March 2022, TikTok videos with the hashtag #mentalhealth had been viewed more than 29 billion times, which shows the popularity of this content.

Many worry this app could be making mental health concerns worse, not better. Recently, several states have begun investigating the potential effect TikTok may be having on young people’s mental and physical health.

Counselors, however, have an opportunity to use these platforms to offset misinformation and educate others on mental health. “Every therapist has their specialties, they have a unique personality, [and] they have something they can offer,” Collazo says. They “can add value to TikTok among all the misinformation.”

Social media can also normalize the process of going to counseling. Collazo’s first TikTok video explained why counselors don’t hug you or hand you tissues in session, and it got more than 200,000 views. That motivated him to keep going. If this information was new to people, he wondered what else could be interesting and educational for them. So, he made videos explaining why counselors have a clock in the room and why the chairs are a certain distance apart.

Many people have an inaccurate understanding of what happens in session, Fleming says. They sometimes assume that they have to talk about anxiety or their feelings the entire time. She’s created TikTok videos that demystify what therapy looks like.

TikTok videos on mental health are “having a big impact on people,” Fleming says, “and helping people recognize it’s OK if they don’t want to feel like this and [that] they can feel better.”

Social media has the added benefit of potentially decreasing the stigma around certain mental health issues. Kennedy has noticed an increase in posts about trauma, neurodivergence and mental health concerns that often have been highly stigmatized, such as autism and obsessive-compulsive disorder. “There wasn’t a lot of information about how it really feels to experience them [these stigmatized diagnoses],” she notes. “And now that we have social media where people are sharing their … experiences of living with these diagnoses, people are resonating with that and noticing the stereotypes of it versus how it actually feels to live with it.”

Social media can also allow more access to mental health care for people who might not be able to go to counseling because of the expense or time constraints, Kennedy says. “Not everybody has insurance that covers it or … can afford sliding-scale therapy,” she notes. The social media content, however, “can allow some access to the beginnings of self-healing work, which is really important.” Counselors can also use social media to connect people with resources and find low-cost counseling services, she adds.

“I do not think the rise of therapists on social media is keeping people from therapy. I think it’s actually helping more people seek out therapy,” Kennedy says. Going to counseling can be scary for many, especially those who have experienced trauma, she continues, “so feeling like you already have a sense of a therapist because of social media can make you feel a lot more comfortable to take the first step in reaching out.”

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Related reading:

“Self-diagnosis in a digital world” (from the April issue of Counseling Today magazine)
“#disconnected: Why counselors can no longer ignore social media” (from the Counseling Today archives)

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Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@counseling.org.

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

Voice of Experience: If it were easy

By Gregory K. Moffatt March 23, 2022

A few years ago, I managed the most complicated case of my professional career. I was serving as an adviser to an agency, and this case required me to manage HIPAA, ethics, confidentiality, supervision, competency in practice, dual relationships, intrusive intervention, the law, risk assessment and a host of other issues that would have been a challenge by themselves. Dealing with all of them at the same time was nearly overwhelming. I couldn’t have managed that case 20 years ago. Most likely, I wouldn’t even have known where to start.

The case wore me out physically and mentally. For more than two weeks, there was something to do every single day — a phone call with the agency, the client, the care providers, colleagues for consultation, and attorneys. Some days I drained my cell phone battery searching through the ACA Code of Ethics, which I always have available to me on my phone.

I worried about the client, potential lawsuits, ethics and my license. I second-guessed myself often, not in a bad way, but just double- and triple-checking my decisions to make sure I hadn’t missed anything. At times I dreaded answering the phone or checking my email. But in the midst of it all, I remembered my own words to my students and supervisees: “If it were easy, anyone could do it.”

I’m closing in on the end of my career, and retirement is never far from my mind. Challenges like the case I just mentioned could easily be the catalyst that drives some people to hang up their hat and retire, but the effect on me is just the opposite. I love what I do, and these types of challenges keep me in the game. With confidence I can say, “I got this!”

I’ve written in the past that I don’t believe burnout exists. In brief, people burn out when they either never had the passion for the job to begin with or when they let the challenges of the job smother the passion they had in the beginning. The former can’t be burnout since there was no flame to start with. The latter can be repaired by reframing or adjusting one’s job to limit the clutter and renewing that passion.

We all face challenges in our career, but when the job gets hard, that is when I am most energized. A newly licensed clinician can manage the easy stuff in the profession. The older and more experienced I get, the better I am at my work, and without challenges, I wouldn’t be doing anything that I couldn’t have done 20 years ago. That is when boredom sets in.

I was a soccer referee for many years and retired from the game as a professional referee doing national and international games. At some point in my career as a referee, I decided I didn’t want to be just another average referee, so I began my journey into the big leagues. I marveled as I watched the very best referees in the game manage exceedingly challenging matches.

I didn’t know if I could ever do that. But as I developed and trained, and as I learned and improved, I made it. I often had butterflies in my stomach as I prepared to blow the kickoff whistle, knowing there were young referees in the stands watching me, just as I had done with other referees many years earlier. There is great energy in professionalism.

As a retired referee, I sometimes reminisce with friends about tough games, mistakes I made, and challenges I faced well. That brings me happiness, and I suppose that is some of what Erikson meant when he taught us about the last two stages in psychosocial theory — generativity versus stagnation and integrity versus despair. I “generated” something valuable, and that brought me to a place of integrity.

The point here is to encourage young clinicians to seek challenges that force you to grow. Don’t be just another average referee — so to speak. And for those of you in the middle or later stages of your career, don’t let challenges drive you prematurely into retirement or out of the profession altogether. You have arrived, and new clinicians need to watch and learn from you.

We get to a place like this by seeking challenges rather than avoiding them. We master our craft by working with the hardest clients, facing the most difficult ethical problems and pushing ourselves professionally in every area.

As the old saying goes, “steel sharpens steel.” You will never sharpen a knife with a soft piece of wood, and you will never sharpen your skills by taking the path of least resistance. You got this!

sydney Rae/Unsplash.com

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

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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.

When counselors grieve: Witnessing a loved one approach death gracefully

By Suzanne A. Whitehead March 21, 2022

My wonderful, dear, precious mother is dying. She has terminal metastatic cancer, adenocarcinoma, that began in her colon and quickly metastasized to her liver. She first started experiencing periodic stomach pains in early 2019, but numerous tests and exams divulged no significant results. We were concerned for her but felt relieved when all tests came back negative. It is with her gracious permission and indominable spirit that I relay our story.

When the global COVID-19 pandemic shut the world down in March 2020, we sheltered in place as most Americans did and prepared to ride out what we hoped would be a short storm. I was teaching remotely from home, and as the coordinator of a counselor education program, I was blessed to be able to make the final decisions on that front. As May 2020 rolled around, my mother complained off and on of more stomach discomfort, but it would quickly fade and was nonspecific. On May 18, however, she woke with great discomfort in her belly. A trip to the doctor led to more tests, and we were finally able to schedule a barium swallow exam for early morning on May 20.

My mother endured the pretest liquids with great difficulty but was eventually able to have the test completed. She came home with us, feeling exhausted and very nauseated. The vomiting soon ensued, and she became increasingly uncomfortable. Our alarm grew after making frantic calls to the doctor throughout the day and taking a resultant trip to the emergency room in a neighboring city.

After my mother had a thorough examination, a surgeon was consulted, and a blockage was located in my mother’s large intestine. Papers were hurriedly signed, and we kissed my mother goodbye. Due to COVID-19 restrictions, no one could stay with her. My mother was 94 at the time and scared to death to face the operating room alone.

The surgeon called us close to midnight. My mother had made it through the surgery OK and (miracles as well) did not need to have a stoma or colostomy bag put in. The surgeon believed he had been able to dissect the entire tumor but would have to test the margins of course. This was a slow-growing tumor, he told us, and my mother had probably had it for some time. Due to her advanced age, even if it ever spread in her colon, she might actually pass away from something else entirely. So, not to worry, he said.

Recovery in the hospital was a nightmare. The first night went well, but my mother had sadly aspirated the next morning and wound up with pneumonia. The medical staff was trying its best to help her, but that becomes trickier with advanced age. My mother is a bit hard of hearing, has short-term dementia-related memory loss and can be a very feisty Italian lady. She stands all of 4 feet, 4 inches and has severe osteoporosis that has resulted in very pronounced scoliosis of her spine. Therefore, she cannot, lie flat and must have the head of her bed propped “just so” to even sleep. I learned later that the medical staff had called the crash cart twice for her, almost losing her in the process.

I tried frantically to get answers as my mother seemed to linger but not improve. Several days went by, and numerous “hospital specialists” were assigned to her case, but none realized all the nuances of her interwoven symptoms. My first career in life, before I became a substance use disorder counselor, school counselor and university professor, was as a respiratory therapist. The names of some of the equipment have changed over the years, but not a person’s anatomy and metabolic processes. I was therefore able to keep up with the physicians regarding the dire circumstances of my mother’s respiratory acidosis, lowered PO2 oxygen levels in her blood, and the infiltrates and atelectasis in her lungs.

The head medical staff finally acquiesced on my mother’s eighth day there, and they let me visit her. My counselor training helped profoundly in working with everyone in her care. My mother was quite in distress when I first arrived, but as is often the case with family visits, began to thrive. The nursing staff said I had to stay put in her room, and they brought me meals and provisions. By the second day, I had her up walking. I swapped places with my grown daughter, and by the fourth day, they said we could take my mother home. It was indeed a miracle that we were able to wheel her out of the hospital.

Twists and turns

We took the rest of the summer of 2020 to help my mother recover. It was slow going, but she gained strength each day. It was decided that the fall of 2020 would be taught remotely at my university, so I looked for a wonderful place for her to convalesce. I was incredibly fortunate to find a condo for rent right on the ocean, and we spent the month of September sitting by the ocean, taking long walks on the beach, watching the boats sail by, and loving every minute of life.

My mother was feeling stronger by October and was even cooking again, which is her favorite pastime. A monthly checkup raised some concerns, and more tests were ordered. To our heartbreak and dismay, the cancer had massively invaded my mother’s liver and was voracious. Her oncologist suggested chemotherapy medication that she could take at home but, sadly, it would perhaps prolong her life by only a few weeks or months. There was no cure or other treatment.

My irascible and feisty mother said she wasn’t ready to give up, so we began the ritual of chemotherapy pills at home just after Thanksgiving. She seemed to tolerate that well until just a few days after Christmas. The pills had reduced the size of her tumors, but she became quite toxic to the point of having constant diarrhea, vomiting and not eating.

January 2021 rolled around, and my mother was still quite ill from the chemotherapy. With incredible strength of will and sheer grit, she fought on and finally began to feel a little better by the end of the month. Her oncologist introduced the chemotherapy again, but at a lower dosage, and she tolerated that well.

By June, her tumor marker blood tests showed that they had been reduced by over half. That was indeed remarkable in and of itself. Her oncologist had thought in October 2020 that my mother might possibly live up to another year; by June 2021, she seemed to be thriving. Incredibly, we were able to bring her to Hawaii that month, where I was presenting at an international conference that had been postponed from the year before. We were so very blessed to have that conference occur during the brief “sweet spot” when COVID-19 seemed to diminish a bit and the delta variant had yet to arrive. The trip was glorious. Several family members joined us, and we were able to visit many places we had gone to when we lived on Oahu a few years previously.

Early July brought another jolt of reality when another severe colon obstruction landed my mother in the hospital. After six days of intense, painful therapy and tests, my mother was slated for additional surgery. Her physician was extremely cautious and tentative about her prognosis. Literally, at the eleventh hour, just before her scheduled surgery, the treatments they had given her began to work. Another miracle had occurred! Three days later, we were again able to wheel my mother out of that hospital, without more surgery. It was a day to celebrate.

Sadly though, by September, her blood tests revealed that her tumors were growing again with a vengeance. The painful decision to stop the chemotherapy was agreed upon, because by then it was doing her more harm than good. Fall 2021 also had its extreme joys, however, as we were able to celebrate our daughter’s very tiny, but beautiful, wedding on Nov. 6. My mother was able to stand up for her as the matron of honor; it was a poignant and blessed day for all.

The long goodbye

The holidays have now come and gone, and again I marvel at my dear mother’s strength and perseverance. Despite our fastidious precautions, with all of us getting the vaccines and booster shots, COVID-19 entered our home in early January, and we all became infected with the omicron variant. It is a true testament to my mother’s will that even COVID-19 cannot stop her. Her symptoms resembled that of a bad cold — something else she could have done without. Thankfully, however, she made it through that horrible hurdle too.

Painful realities remain though, and we all agreed in late January that the time had truly come to begin the hospice process. I have never had hospice services for a loved one before, and there was a lot to learn. Some of the realities were quite painful, such as that my mother cannot see her established physicians any longer. We’ve also been asked several times to consider a “Do Not Resuscitate” order; we’re not quite there yet. I am reminded once again that death and dying is a process, not an event.

A plethora of nurses, social workers, delivery workers (bringing oxygen tanks, shower supplies and comfort meds) and a minister for spiritual support have come to visit. The very slow reality of the long goodbye is now at hand. As a counselor and university professor, I “know” about self-care, the many aspects of grief and loss, the need for continued support, and the existential angst one feels when realizing that nothing else can be done. It is an empty, hollow feeling that begets profound sadness.

I am extraordinarily blessed with wonderful family support. My husband and I have three grown children (two of whom are nearby and one six hours south), a wonderful son-in-law and daughter-in-law, and two amazing grandchildren. My university colleagues have been immensely supportive, as has my faculty and staff. I have the dearest friends one could ask for but, sadly, most are a great distance away. The miracle of iPhones and the internet have helped with that.

The pandemic has brought innumerable obstacles and immense sadness, pain, distress and heartache to us all, in one form or another. For us, it has meant that the last remaining months and days of my mother’s life must be limited to home. Yet serendipitously, I have been given even more precious moments at home with her. The days of shopping together, visiting nearby museums, going on short camping trips or talking for long hours at a lovely luncheon spot have all ceased. Instead, the tiny joys of taking an afternoon walk, watching a great movie together or enjoying the sunshine and warmth on our faces have taken on greater significance.

I marvel at my mother’s internal strength, her spirit and her deep love of life. I sit in despair sometimes as I watch her try to catch her breath, see her moving much more slowly, and recognize the distant look in her eyes; I wonder where she has drifted off to at times.

We talk often. She shares her innermost fears, regrets (blessedly, very few), and final wishes with me. These are sometimes painful talks, but they are necessary, cathartic, and I let her choose her timing.

I find myself walking with great trepidation down the long hallway to my mother’s bedroom in the morning when I haven’t heard her stir yet. Will I at some point just find her gone, peacefully? Will she have to suffer greatly (I fervently pray that she doesn’t), as my dear father — her husband — did from cancer so many years ago? Will I be able to let her know how very, very much she has meant to me, how much she is so dearly loved by us all? Can I properly express that without her, I never would have become the counselor, teacher, mentor and social justice advocate that I am? My family and I have been blessed by her comfort, wisdom and beautiful spirit for close to 96 years now. Letting go by inches is so incredibly difficult …

A shared reality

So many of my dear counselor colleagues, friends and students have lost loved ones due to COVID-19 over the past two years. We have shared this reality as human beings, and together we mourn each loss. I have been honest about my mother’s condition with all of them so that they realize that even counselor educators deal with grief and loss. I teach all my students about the vital importance of knowing your limitations, knowing when to reach out for support, knowing when to step back and take a break, knowing when you are not at the “top of your game,” and knowing that it is OK for us to be fully human.

Perhaps putting my thoughts into words here is just my way of doing so. I hope that for those who have endured or are enduring similar circumstances, my words can offer some support, connection and solace. It is our humanity and spirit as counselors that binds us.

So too, as counselors, each of us has helped dozens, if not hundreds, of people cope and work through their grief and loss. It is part of our very nature. It is what we do, and we are honored to do so. We have learned our craft well and know what to say, how to say it and how to sit with another human being during their profound sense of pain and despair. We must make that kindness and compassion that we so freely give to others available for ourselves as well.

My mother is dying with grace; I am learning from her strength to honor her journey thusly. I will grieve horrifically when she passes. She has asked me not to grieve so, but that would be impossible. What a gift she has been to my entire family, that she even worries about how we will feel once she is gone! The price we pay for loving someone so fully, so unconditionally and so openly is to grieve their passing with our whole heart, soul and being. To have been eternally blessed with her love, I would not have it any other way.

Leon Seibert/Unsplash.com

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Suzanne Whitehead is an associate professor and the program coordinator of the counselor education program at California State University, Stanislaus. She is a licensed mental health counselor, a retired school counselor and a licensed addiction counselor. Contact her at swhitehead1@csustan.edu.

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