Monthly Archives: April 2022

Voice of Experience: How do you know?

By Gregory K. Moffatt April 27, 2022

My supervisee (we’ll call her Tasha) sat back in her chair and, with a look of confidence that I love to see in a first-year supervisee, told me that she had a successful session with one of her clients.

“I feel really good about it,” Tasha said.

I love watching the tentative and fearful looks that I see during the first few months of supervision gradually transition over to those first glimmers of “I’ve got this.” But that evolution also makes me nervous.

“Tell me about your feelings of confidence, Tasha. What happened that makes you confident you did a good job?”

Tasha reported that the client had made progress the week before after several weeks of stagnation in their work together. That is a good sign of course. But then Tasha said something that always raises a red flag in my supervisor’s brain.

“I don’t know, but I was explaining … and it just felt right. I think I got through to my client.”

I don’t know whether Tasha got through to her client or not, but the fact that she couldn’t operationalize it, along with the fact that she was “explaining” something to the client, made me nervous.

We’ve all been there as counselors. Everything just seems to click, and we close a session feeling good. But we also know that, in general, our feelings are not always trustworthy.

I suspect Tasha’s good feelings were reflective of her “explaining” things rather than anything the client did or said. Nothing is wrong with a little psychoeducation, but explaining well doesn’t mean that Tasha’s client “got it.” In fact, confidence based on her own feelings could even increase the probability that Tasha would miss it if her client didn’t get it.

Most veteran therapists at one time or another have felt good about a session only to find out later that their client didn’t share that feeling. The opposite is also true. Sometimes when we aren’t certain that we have connected well, we find out later that the session was a breakthrough moment.

I’ve made this error myself. I once worked with a young man who was strong, energetic, mature for his age and very verbal. He was one of those easy clients we all enjoy seeing on our calendars.

I thought we had hit it off pretty well in our first session and looked forward to each week with him. But after four or five sessions, he stopped coming. After he missed two sessions, the receptionist in the agency where I was working reached out to see if he wanted to reschedule.

Clint Adair/

As you can easily predict, he didn’t reschedule. What was more disheartening to me was his reason. He told the receptionist that he just didn’t feel like I was the right fit and that he had decided to go elsewhere. He shared no details beyond that, but I’ve never forgotten about what happened.

My mistake was errantly assigning the cause of my feelings. I supposed that I felt good because he was connecting with me when, in fact, I most likely was feeling good because of things about me. Yikes. It is never about us.

I’m always happy when new clinicians experience successes. It would be a miserable career if we never had those positive experiences and interactions, so I celebrate their successes. But I don’t stop there. I always ask why they think it went so well.

If the answers have to do with “gut feelings” or something about the clinician, I suggest caution. The session might have been amazing, but I don’t trust feelings that I can’t operationalize.

Feelings are unstable things on which to base decisions. Most of us have had an experience where we were positive that a relationship in our personal lives was right, only to be equally convinced sometime later that it wasn’t. Our initial feelings about relationships are often based on newness, first impressions, expectations, appearances, sex or other shallow pieces of data. As the relationship progresses, the more important data points eventually become evident and are much more reliable than our initial feelings.

It is the latter data set that tells us if we should continue the relationship, adjust it or terminate it. And that same type of data analysis should be part of assessing our feelings about our sessions.

Feeling good about a session is fine; just ask yourself why you feel good. If it is because of something that your client did, said or presented, great! But if you can’t nail that answer down, be cautious.



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.

Self-esteem: Tending to the roots and branches

By Bethany Bray April 25, 2022

Self-esteem is tied into nearly everything, from career and relationship issues to anxiety and other mental health challenges, that bring clients through the counselor’s door. And if their self-esteem is unhealthy and out of balance, it hinders clients’ ability to grow and heal from their presenting issues — unless they first address how they feel about themselves.

“You need self-esteem in order to live a life that is really meaningful to you, and you won’t know what’s meaningful to you unless you know yourself,” says Katherine Hennessy, a licensed professional counselor (LPC) and certified alcohol and drug counselor at a group private practice in Lake Oswego, Oregon.

Hennessy views self-esteem not as a commodity to have in varying amounts but rather as an integral piece of working toward the therapeutic goal of self-actualization. She has seen clients who struggle with overconfidence or have difficulty recognizing their shortcomings, but that doesn’t mean they automatically have an overabundance of self-esteem.

“Self-esteem is an achievement; it’s not something you can have too much of. We are born with abundant self-esteem, and the world picks away at it as we get older, so it’s an achievement to get it back,” Hennessy observes. “Self-esteem is the foundation for mental health. Having healthy self-esteem means that we know that we deserve to be treated with respect by ourselves and by others. We must believe that our wellness and happiness are worth fighting for and that we are capable of making positive changes in our lives in order to work toward our therapy goals.”

On the surface

Self-esteem “definitely touches all of my clients in one way or another no matter their diagnosis, or even [in those with] no diagnosis,” says Ariel Cross, an LPC who owns a private practice in Denison, Texas.

Stagnation or lack of growth in counseling work and in life, such as career choices or relationship patterns, can be an indicator that a client’s self-esteem is out of whack, Cross notes. This can be the case both when an individual is overconfident (what Cross calls “insecure self-esteem”) and when they lack confidence and believe they are not good enough.

For clients with insecure self-esteem, lack of growth may include frequent job hopping, poor impulse control, an inability to accept or learn from criticism, irritability, anger or a pattern of blaming others (e.g., becoming angry at a boss who gives critical feedback in a performance review instead of recognizing it as an opportunity for growth or improvement). These clients often have a mindset that asserts, “It’s not me, it’s them,” Cross says.

Clients who struggle with low self-esteem, on the other hand, may be stuck in patterns that include staying in jobs or relationships that aren’t fulfilling, healthy or a good fit for them. They generally lack the confidence to seek or picture themselves in a better situation. Cross says these clients may have internalized the message “I’m not good enough.” 

Patterns of accepting and allowing others to treat them poorly can be a sign that a person has low self-esteem, Hennessy adds, as can behaviors that indicate they don’t trust themselves, such as asking a lot of questions or constantly seeking advice from others. When low self-esteem copresents with depression, it can manifest as listlessness or hopelessness. These clients simply may not know themselves well and struggle to find things that they enjoy or are good at, from hobbies to job skills, Hennessy says.

“If you have low self-esteem, you don’t know what you’re worth, what your value is or what’s important to you. You only know what others have told you,” she says. “You most likely don’t have a job that is meaningful to you or relationships with those who value you.”

Vanessa Wells is a licensed mental health counselor and school adjustment counselor for ninth and 10th graders at a charter high school in Salem, Massachusetts. She has past experience working at a residential clinic for clients with eating disorders. She says self-esteem challenges are often an underlying issue for students who come to see her because they are experiencing conflict with peers. This is especially true for individuals who are not (or who feel they are not) being valued or heard in their interactions. This can present as an inability to understand others’ perspectives or opinions without feeling devalued or retaliating in an unkind way.

Wells notes that self-esteem challenges in youth can also manifest as:

  • Excessive apologizing
  • Cognitive rigidity, inflexibility or perfectionism
  • Isolating behaviors (staying home or not engaging
    with peers)
  • Camouflaging (taking measures to hide their body, such as wearing overly baggy clothing or arranging their hair to cover their face)
  • Negative tones or attitudes about others 
  • Self-deprecating statements or humor

Boundaries and self-esteem

Shelby Turner, an LPC who counsels teenage and adult individuals at her solo private practice in the Greenville, South Carolina, area, helps clients work on creating and enforcing both physical and emotional boundaries. She finds this work is most often needed with individuals who struggle with low self-esteem.

Individuals with low self-esteem often agree to or put up with things they don’t like or aren’t comfortable with because they lack confidence or struggle to speak up for themselves. Boundary setting can be a powerful tool for these clients to begin breaking those patterns, Turner says.

For example, a youth who doesn’t like having their hair touched may just go along with this unwanted behavior from peers at school or in social settings. A counselor might help the client learn to voice their preference and set a physical boundary by saying, “I’d prefer a hug or high five, but please don’t touch my hair,” Turner suggests.

Setting an emotional boundary involves identifying ways that others hurt or dominate the client and then finding ways for the client to express their needs and ask for a different behavior. For instance, a counselor and a client might create a plan for the individual to ask their partner not to raise their voice or use insults during arguments. If the partner continues that behavior, the client would end the conversation and continue it only after the partner has de-escalated. If the partner violates the boundary again, the client could respond by leaving the room or otherwise separating themselves from the person, such as by ending a phone call or leaving a text message unanswered.

“I have to educate people a lot to help them see what they deserve, [emphasizing] that boundaries are helpful and OK and healthy, and that it’s OK to say ‘no’ sometimes,” Turner says. “It means ‘I respect myself too much to let you treat me this way.’”

(For more on boundary setting with clients, see the articles “When the behavior of others negatively affects clients’ mental health” and “The sensitivity of boundary setting in collectivist cultures.”)

Values: Getting to the root

The need for acceptance is part of who we are as human beings, Cross notes, so it is only natural for self-esteem to be central to decision-making and behaviors that counselors see in clients. Self-esteem often correlates to messaging and feedback that an individual received at a young age. Over time, those messages can become internalized as values.

“From zero to age 5, our self-worth and values are formed,” Cross notes. “If you grew up with neglect or within a traumatic household, it can affect your sense of self.”

Improving self-esteem then must involve exploring and dismantling unhealthy values and beliefs that clients have internalized — often unbeknownst to them, Cross says.

Turner agrees, citing an example: If a female client heard comments throughout childhood from a parent or other loved ones along the theme of “you need to watch what you eat; you’re getting chubby,” she may come to believe that her worth is based on her weight and clothing size. When messaging comes from people whom the client turned to for love and acceptance as a child, it can be difficult to think in a different way, Turner says.

Turner uses cognitive behavior therapy (CBT) to focus on unhealthy core beliefs that clients have internalized. She refers to these beliefs as “the roots of the tree.” 

“Cognitive distortions are the leaves; you can keep plucking the leaves off, but they’re going to keep growing until you address the root,” she says.

Cross pulls from several methods, including CBT, to explore clients’ beliefs and values “to the core,” she says. The ultimate goal is to have clients move toward self-compassion and acceptance of all the parts of themselves, including their flaws.

If a client makes a comment that reflects a negative self-belief (e.g., “I’m not good enough”), Cross will challenge their statement. She’ll ask, “Think back through your past. When was the first time you felt that way?” She doesn’t expect the client to answer immediately. She often has them think through this question on their own, and then they discuss it together at their next session.

Hennessy also works to guide clients to a place where they can recognize their thoughts without reacting or responding to them. They cultivate the ability to pause and ask themselves, “Where have I heard that before, and is it actually true for me?”

“It takes a lot of time [for clients] to become comfortable with the idea that we can be influenced by things, especially those we aren’t aware of,” Hennessy says. “We are individuals and don’t like the idea of outside things making us feel a certain way.”

Clients who struggle with self-esteem often don’t know what their values are, Hennessy notes. She uses mindfulness techniques to prompt clients to pay attention to their cognitive distortions and how they feel in their body when they discuss subjects such as body image that are tied to internalized beliefs. This technique teaches clients to identify cognitive distortions that are negative and in need of correcting. But it also can help them learn what thoughts and values do feel good so that they can begin to focus and emphasize those aspects in their life and decision-making.

This was the approach that Hennessy took with an adult client who was unhappy at her job as a medical receptionist. Hennessy guided the client to be mindful of how it felt as she thought and talked about which aspects of her job did and did not align with her personal values and traits.

After some introspection, the client discovered that what she hated about the job — and what made the position a mismatch for her — was scheduling tasks and data entry. Because she disliked those aspects, she often made mistakes when entering data, which led to a cycle of feeling bad about the job and herself.

However, what she did enjoy was talking with patients to understand their medical history and connecting them to the appropriate help. This realization led her to seek a position that would align with her values and allow her to engage with people more. She eventually transitioned into a job as a case coordinator.

“She came to realize that she shouldn’t be behind a desk at all,” Hennessy recalls. Not only was she happier and more fulfilled in her new job, but the client’s self-esteem lifted because she finally felt that she was good at something, Hennessy notes.

Wells does values exploration with almost all of the high school students she counsels, most of whom have never been in a therapy setting before. Not only are they unfamiliar with their values, but many do not have the language to express what they are feeling or thinking in
this realm.

Wells uses mindfulness techniques and a number of worksheets and tools to equip them with vocabulary and prompts to identify their core beliefs. This includes a values “card sort” activity that uses a deck of 50 cards, each with a value such as honesty and an explanation of that value. Students arrange the cards into categories based on how important the value is to them (e.g., most important, least important). Wells talks with the students while they sort the cards and prompts them to think about their values by asking questions such as “What decisions might you make in your life based on this value?”

It’s developmentally appropriate for teenagers to struggle with making healthy choices, Wells notes. Values work can be an empowering way for young clients to hone these skills. 

This was the case with one student who had previously done the card sort activity with Wells and identified honesty and friendship as the values that were most important to them. The teenager came to see Wells again after experiencing friction in their friend group. The student had made a conscious decision to tell a lie to “create drama” among her friends, which resulted in relational struggles and negative reactions from her peers, Wells recalls. As a result, the student experienced feelings of guilt and an increase in depressive symptoms. Wells helped the student realize that the decision to lie was incongruent with the values they had originally identified in counseling, and together they brainstormed ways that the student might make different choices in the future. 

Thought patterns and self-talk

The self-talk that people hear is based on their core beliefs, and when those values are unhealthy, they may be bombarded with messages such as “I’m not good enough,” “I’m ugly,” “The rest of the world is the problem,” “I’m unworthy” and other problematic thoughts. It is imperative that counselors help individuals with unhealthy self-esteem to address and repair both their core beliefs and the self-talk that stems from them.

Humans are very good “rehearsers,” Cross notes. We often can’t stop ourselves from rehearsing and hearing in our minds what we assume others will say or feel about us. A large part of the work in counseling often involves “reality checking” these patterns with clients, she says.

Cross advises counselors to gently challenge clients’ negative thought patterns rather than abrasively confronting messages that clients may have internalized and lived with for so long. She once heard a counseling colleague describe this approach as “care-frontation” rather than confrontation. Cross often uses Socratic questioning and CBT to gently “care-front” her clients about their unhealthy thinking. 

For example, a client may express that they’re unhappy at their job. They are anxious and have a low mood, and they hate the thought of going to work. Cross would prompt the client with a question: “What makes you stay at that job?”

The client may respond by expressing fear: “I don’t even know how I got this job,” “I’ll never get another job” or “I don’t feel worthy of another job.”

The client is stuck in a pattern of rigid thinking, and the root is that they don’t feel they are good enough to be in a different situation, Cross says. From here, she would deploy “care-frontation” and challenge their thinking by pointing out past successes.

“You got this job,” Cross would tell the client. “You may feel it was lucky, but is that true? Usually people don’t stumble into jobs — they earn them.”

She finds Socratic questioning can be especially helpful for clients who struggle with cognitive distortions related to self-esteem. She often gives these clients printed questions on a piece of paper or notecard that they can keep with them and refer to when needed. Cross once counseled a client who experienced panic attacks. He kept a list of Socratic questions in his wallet and would pull it out when he began to feel triggered, she recalls.

These types of questions can include:

  • What is the evidence for this thought, and what is the evidence against it?
  • Am I basing this thought on a fact or a feeling?
  • Could I be misinterpreting the evidence or making assumptions?

Turner suggests a first step in counseling clients who struggle with self-esteem may be to introduce them to the idea that their feelings and thought patterns can be challenged or changed. An important aspect of this work, Turner adds, is to help clients learn to respond to their self-talk with accuracy, not necessarily positivity. For example, a client who is hesitant to seek a raise at work may feel that there’s no point in asking because they won’t get the raise and their boss will laugh or think they’re stupid for bringing it up. Instead of making positive statements such as “Oh, that won’t happen,” “You’ll be fine” and “Don’t worry,” a counselor could prompt the client with questions that separate feelings from fact:

  • Does my job performance support a raise?
  • Has my boss ever laughed at me or called me stupid before?
  • Are my co-workers getting raises?
  • Is the raise amount I’m asking for reasonable?

“It’s not ‘good vibes only’; it’s thinking accurately,” Turner says. This work is “reframing and learning how to think more accurately, not just more positively.”

Wells agrees, emphasizing that positive affirmations are one tool that is not appropriate for clients who are working on self-esteem in counseling. She urges practitioners to keep their statements and questions as neutral as possible, especially when working with teens.

Perhaps a client mentions a belief with the theme of “everyone hates me” while talking in session. Wells says the counselor could respond neutrally by asking the client to name examples of influences in their life, such as a parent or a loyal pet, who have expressed that they don’t hate the client. She often emphasizes to her young clients that we are “not mind readers” and don’t actually know what others are thinking or feeling about us.

“Trying to do positive affirmations is not helpful in the grand scheme of things because they [clients] won’t believe it. But what they can’t push back against is neutral facts,” Wells stresses.

Instead, Wells uses CBT as well as acceptance and commitment therapy, motivational interviewing, narrative therapy, Socratic questioning and role-playing to talk through and explore clients’ experiences and self-beliefs that influence their thought patterns and behaviors. 

Group work can also be a powerful setting for clients to work on social skills and self-esteem in tandem, Well notes. Sometimes she gives her student groups prompts — such as “What would you do if X scenario happened?” — to role-play together or to write about in their journals at home and discuss at the next group session.

A sense of self

Jon Soileau, an LPC and managing partner at a small private practice in downtown Kansas City, Missouri, estimates that roughly half of his clients enter counseling acknowledging that self-esteem is something they need and want to work on. Soileau counsels from a contemporary psychoanalytical approach. So, self-esteem, as it relates to clients’ ego or sense of self, is central to his work, he says, and many clients seek him out for that reason.

Soileau explains that a person’s sense of self involves their level of comfort with who they are. Self-esteem is just one component of a person’s sense of self, along with their personality traits, moral code, belief systems, likes/dislikes and other aspects that make them unique.

Self-esteem struggles, including lack of confidence, concern over what others think about them, and the inability to process emotions, are often a sign that a client’s sense of self is underdeveloped or “soft,” or that the client is simply unaware or out of touch with it, Soileau says.

He takes a two-part approach — a process he calls “holding and uncovering” — when helping clients to develop and improve their sense of self. In the primary, holding stage, Soileau focuses on listening to the client and remaining curious. He also uses free association to prompt clients to talk about things they are struggling with, their life history and what brought them to counseling. While the client speaks, he invites transference, taking in the many nonverbal cues that the client is expressing in addition to their spoken words. For example, a client’s tone may rise or change when they talk about a certain topic. This provides him with more information and gives him an opportunity to ask for additional details, he says.

“The cognitive pieces are very important, but [so are] the affect in the room and what we can hear, see and feel from the patient,” he says. “I let all the details of what’s going on with the patient wash over me.”

During the second phase of therapy (uncovering), Soileau guides the client to understand and dig into why they feel the way they do. “Rather than targeting self-talk, I focus on what’s influencing the self-talk — the very root of what’s going on,” he says.

Soileau sometimes uses enactment to help clients work through a troubling pattern or scenario with which they are struggling. For example, a client may not do well in romantic relationships but doesn’t understand why. Their relationships typically go well for a while, but they always end badly and the client’s feelings are hurt.

Soileau would invite a similar scenario to happen in counseling so that he could process it with the client. Perhaps the client misses a session and Soileau charges a no-show fee, causing the client to respond in anger — as they do in all their relationships. “From there, we can process it and work through it together,” Soileau says. “In session, I … would allow it [the angry blowup] to happen in a way that’s controlled and healthy.”

This deeper work on the roots of a client’s feelings and patterns should happen only after a strong and trusting therapeutic bond has been established, he says. Delving into these issues before a client is ready can damage the client-counselor relationship and cause the client to stop coming to appointments, he explains.

Soileau takes a relational approach in his work with clients and says this therapeutic connection is central to fostering the level of comfort that clients need to open up and work on their self-esteem and underlying issues. Fostering the therapeutic relationship is a focus “from the first minute I interact with a patient,” he says. “The therapeutic relationship is fundamental. We need to make them feel at home and able to be themselves — their true self — and not the person that they feel they have to be outside of the therapy room.”

Empathy without reassurance

When working with clients who have unhealthy self-esteem, it can be heartbreaking to hear them use statements such as “I’m not worthy” or “I’m not good enough.” Counselors must suppress the urge to respond with reassurance, however.

Clients with low self-esteem often seek reassurance, but at the same time do not fully believe others when they respond positively and contradict the clients’ self-beliefs. Turner says the crux of counseling work in this realm is to break these patterns so that clients can identify their beliefs as inaccurate and something that is within their power to change.

It is a natural human urge to contradict clients when they say something like “I am ugly,” Turner acknowledges. But “rescuing” a client from this thought is both inappropriate (because counselors should not be commenting on a client’s appearance) and subverts the very skills that the client needs to develop on their own.

“My opinion does not matter; my job is to help them do the work,” Turner emphasizes. “I have to remember that it’s not my job to reassure; it’s my job to help that person identify and challenge inaccurate ways of thinking. That goal is not going to be accomplished if I just reassure them that they’re not ugly.”

Hennessy agrees and urges counselors to respond to clients who are seeking advice (which is common among people who second-guess themselves) with more questions, not suggestions. An important part of this is acknowledging and honoring that the client is in the process of making a difficult decision and has made good choices in the past.

Hennessy uses mindfulness to prompt clients to assess how they feel in their body when they think about a tough decision. She might ask the client, “What does your intuition feel like? What does your gut tell you? What does it feel like when you think about doing A versus doing B?” 

“It can feel cold to respond with questions [such as] ‘What do you think about that?’” Hennessy admits. However, clients “have to validate themselves. It doesn’t help them grow to get validation from an external source [the counselor]. … Counselors will have a reflex to reassure and comfort clients, and we have to put our therapy hats on really snug to stop ourselves from doing that.”

Turner says she often reminds clients that “healthy self-esteem is something that we all have to work at; it doesn’t come naturally.”

She also emphasizes to clients that dismantling long-held beliefs requires hard work and repetition. “There’s no quick fix,” she says. Training your brain to learn new thought patterns is like blazing a trail in the woods, Turner asserts. You have to visit it and walk over it repeatedly for it to become established, worn and comfortable. 

Turner also emphasizes that clients are welcome to return to therapy at any point after they conclude their work together. This message is important for all clients, but especially those who struggle with their self-esteem, she says. She stresses to clients that it is normal for struggles to ebb and flow throughout the course of a person’s life and that it is not a sign of failure to seek a “refresher” with a counselor when their current tools and coping techniques are no longer meeting their needs.

“Clients often need to hear things over and over again, [as] we all do,” Turner says. “I have seen people come out of these really deep patterns [cognitive distortions] once they know how to identify them and open their minds to thinking a different way. It opens a world of possibility to realize how negative and inaccurate thinking affects all aspects of our lives.”

Sabrina Bracher/


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


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

Counseling Connoisseur: Nature therapy and brain science in children

By Cheryl Fisher April 20, 2022

Alfred Adler purported that all behaviors have a purpose. Behaviors are often the way the body responds to life’s stressors, especially for children. Yet, many therapeutic treatments for children focus on the modification, remediation and even elimination of a behavior without addressing the underlying cause. This approach suggests that once a behavior is corrected, the child will experience general wellness.

Brain science, however, indicates that the physiological state of children must be attended to before one addresses behavioral change. In Beyond Behaviors: Using Brain Science and Comparison to Understand and Solve Children’s Behavioral Challenges, Mona Delahooke, a licensed clinical psychologist, argues, “When we see a behavior that is problematic or confusing, the first question we should ask isn’t ‘How do we get rid of it?’ but rather ‘What is this telling us about the child?’”

Therefore, behavior is adaptive and a response to the internal and external experience of the child.

Autonomic response refresher

The human body responds to perception of threats to safety by creating a biochemical and physiological state prepared to move the body to fight, flight or freeze. In this state, the body increases the production of adrenaline, norepinephrine and cortisol. The amygdala and the limbic system become activated and temporarily lead brain functioning over the prefrontal cortex, which is responsible for higher order thinking and executive functions. The child is now functioning in survival mode, and the child’s behaviors may manifest in a variety of ways, including distraction, withdrawal, irritability or fidgeting, fearfulness, regression, and aggression.

Rather than blindly rewarding or punishing the child’s behaviors, neuroscience suggests that we seek out the cause of the behaviors before addressing them. It begs us to answer the questions, “Why is the child acting this way? Is the child perceiving a threat to safety?”

As I have addressed in my book Mindfulness and Nature-Based Therapeutic Techniques for Children, counselors must consider if the child is functioning from an underdeveloped kinesthetic system (our sense of our body in space) or vestibular system (associated with the inner ear and balance) resulting from lack of free-form movement. So much of children’s time is spent sitting at their desks or in front of devices, or in structured activities. They lack nondirected, unstructured play and movement. What is the underlying cause? How is the behavior serving to protect the child? Most important, how can we, as counselors, help the child resume a sense of safety and balance and experience a calm and alert state?

Brain science

Several models have emerged over the past few years that emphasize the role of the physiological state of children when treating their behaviors. All these models assume that the behaviors are an attempt to cope with internal or external stressors.

Stephen Porges, the founder of polyvagal theory, proposes that mammals have two neural pathways. The first, the social engagement state, is accessible when the child feels safe and can trust the environment, promoting a calm state accompanied by prosocial behavior. The second pathway is engaged when the child feels unsafe.

Porges introduced the term neuroception to describe the body’s way of scanning the environment for threats to safety. At times, the body miscalculates the risk of safety. According to Porges, the symptoms of faulty neuroception are translated to psychiatric labels and disorders. In other words, a child who has experienced trauma may have a vulnerable nervous system that detects threats that do not exist. Resulting behaviors may include hypervigilance, insomnia, paranoia, bedwetting or a host of other regressive or safety-seeking responses. On the other end of the spectrum, the child may ignore actual risks in the environment, resulting in greater threat to self and psyche.

Therefore, based on neuroscience, Porges recommends providing children with individualized cues of safety that allow social engagement behaviors to emerge spontaneously. According to Porges, three situations must be present to feel safe. First, the autonomic system must not be in a defensive state (fight, flight or freeze). Second, the social engagement system must be activated, which results in the downregulation of the sympathetic nervous system and promotes prosocial behavior. Finally, there must be cues for safety (vocalizations, gestures and positive facial expressions) detected via neuroception. The assumption is that cues for safety can only be exhibited and detected in human-human interaction. However, research continues to support that human and more-than-human interactions also afford meaningful connection.

Brain science and nature

Engaging in the natural world has long been known to have a calming effect on the body. A biochemical exchange occurs in the natural world that results in by-products that, when inhaled or absorbed by the human body, produce a calm and alert state. The earth’s core is like a battery that emits negative ions. Blue spaces (oceans and waterways) offer ionic by-products. Additionally, green spaces (forests and parks) produce phytoncides and terpenes.

Fifteen to twenty minutes of being in a natural setting affects the body by decreasing cortisol, norepinephrine and adrenaline (hormones released when the body perceives threat); increasing serotonin; and reducing blood pressure and respiratory rate. The body responds to the natural space by engaging the relaxation response. Additionally, the immune system is enhanced by both an increase in number and activity of natural killer cells. These effects are sustained for up to a week following single exposure to forests and as long as a month following two days of engagement in green space.

David Clode/

The earth communicates through the production of these chemicals, and the human body responds to many of the messages (safety cues) by reducing the body’s defensive state, activating the social engagement system and promoting homeostasis (i.e., a calm and alert state).

Research is conclusive that children who engage in natural settings experience greater well-being, are calmer and demonstrate more prosocial behavior. For example:

  • In their article “The role of urban neighbourhood green space in children’s emotional and behavioural resilience,” Eirini Flour and colleagues found that children impacted by poverty and living in urban settings experience improved emotional well-being when exposed to neighborhood green space.
  • Diana Younan and colleagues noted in their article “Environmental determinants of aggression in adolescents: Role of urban neighborhood greenspace” that exposure to greenspace within 1,000 meters surrounding residences is associated with reduced aggressive behaviors in youth.
  • Andrea Faber Taylor and Frances Kuo discovered that, in general, children who play regularly in green play settings are calmer and more alert than children who play in concrete outdoor and indoor settings. Their study, “Children with attention deficits concentrate better after walk in the park,” also found that children with attention deficit/hyperactivity disorder who play in green open areas versus areas with trees and green grass show milder symptoms.

Although it is becoming increasingly important to integrate outdoor activities into clinical practice, routine access to green and blue spaces may be hindered by many factors. In this case, we turn to indoor alternatives.

Nature therapy indoors

Ecotherapists are capitalizing on the research by integrating nature-informed practices and activities into their work. My own research examines the use of nature-informed sensory “time-out/time-away” stations in the emotional and behavioral regulation of school-age children. Historically, time-out has been used to remediate unwanted behaviors in children. This often involves using a corner of a room without windows or distractions. Once the child has calmed down, they may return to the group setting.

However, if (as Adler suggests) all behaviors have a purpose, then the child has learned only that the presenting behavior is unacceptable and to suppress their natural response to whatever triggered it. They have not learned to self-regulate and address the underlying emotional or physical state.

A nature-based sensory time-away station, however, is imbued with items such as plants and herbs that emit terpenes. The station may have a tabletop sand garden that provides tactile exposure and promotes mindfulness. Additionally, nature soundtracks may play in a headset to allow the brain to register these soothing frequencies.

The preliminary data continue to demonstrate that children are able to use this time-away station as a self-regulating tool to allow for the relaxation response, calming of the amygdala and engagement of the prefrontal cortex. Children engage with the natural material, feel more grounded and (depending on developmental stage) are better able to articulate their underlying state verbally or through expressive arts. They return to their previous activity feeling calm and alert.

Here’s some advice on how to create and introduce a nature-based sensory time-away station:

  • Create the station. A nature-based sensory station may be created indoors or outdoors. It includes physical elements that engage the senses. Items may include edible plants and herbs to promote exposure to terpenes. Cotton balls soaked in essential oils also can provide exposure to terpenes through smell. Small containers of rocks, sea glass, pinecones, feathers and shells can provide the child with different tactile experiences. A small tabletop sand garden with miniature rakes can be purchased or created for a tactile and mindful activity. A betta fish or small fish tank may also add biodiversity to the space. Nature sounds can be streamed through headphones. Additionally, paper and tools to write, color or paint may aid in the communication of triggers once the child begins to enter a calmer state. And items can be rotated to capture seasonal changes to your nature-based sensory station.
  • Introduce the station. Because this is a novelty, everyone in a group setting such as a classroom will want to play at the station. It is important to allow each child a chance to explore the space. Using a timer, have children take turns engaging in the station. When the time is up, they may return to the classroom activity. If introduced as a tool, children will soon learn that this space can be accessed to help regulate emotions and behavior in a productive manner. In essence, the children will learn that they feel better after spending time interacting with the space.

In the home setting, the child can help create the space and be taught that it is a place to go to reboot. Show the child how to engage with the multisensory space and then leave them to their own processes.

In addition to the many ecotherapeutic homework assignments and interventions available, counselors utilizing this space as a co-therapist in the field can introduce the benefits of nature-based multisensory engagement and help their clients learn to self-regulate outside of the therapy session.

In conclusion, behavior is a response to interpretation of internal and external stimuli. A child who feels unsafe may experience physiological arousal and respond in a defensive manner. As counselors, we can help educators and parents learn to address a child’s physiological state by creating safety cues for the child. By introducing a nature-based multisensory space, children can learn ways to reduce defensive states, increase homeostasis and activate their social engagement system.



Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online master’s in clinical counseling. Her research interests include examining sexuality and spirituality in young women with advanced breast cancer, nature-informed therapy and geek therapy. 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.

Suicide attempt survivors: How counselors can help with disclosures

By Joan M. Flynn April 15, 2022

I haven’t shared this with many people, but last year, I was struggling and tried to take my life.

— sample disclosure script


As suicide rates have risen to the 12th-leading cause of death in the United States, the number of suicide attempts has risen as well to an estimated 1.2 million in 2020, according to the American Foundation for Suicide Prevention.

Because suicide attempt survivors are at higher risk for both fatal and nonfatal suicide attempts, disclosure of past attempts is an important aspect of their mental health treatment. Yet research published in the American Counseling Association’s April 2022 Journal of Counseling & Development (JCD) indicates that many survivors choose not to disclose to their counselor, or they may choose to disclose to others in ways that increase their own social risks.

CT Online interviewed Lindsay Sheehan, a licensed clinical and rehabilitation counselor and lead author of the JCD study, to find out more about how counselors can better assist clients who may be thinking of suicide, have made a past attempt or are considering disclosing this aspect of their life to others.



What is most important for counselors to understand about how suicide attempt survivors make disclosure decisions, and why are such disclosures important in counseling?

People who have survived a suicide attempt are more at risk for ideation and future suicide attempts, so disclosure of a past attempt opens the conversation for talking about it in future times of need. It is much easier for a counselor to provide support if they know the client’s history, such as the circumstances of a past attempt, before there is another crisis situation. Counselors, friends and family members can be proactive in supporting the person’s mental health, knowing what to do and discussing with the person how they want to be supported in the event of a future crisis and what they don’t want to happen.

Often, a suicide attempt is an important part of someone’s life journey and even their identity, but seldom is it considered acceptable or is talking about it encouraged. Counselors should keep in mind that talking about suicide makes one very vulnerable — counselors need practice to be comfortable talking openly about suicide, and they need to make sure they are conveying to the client that they are comfortable with it.

Becoming comfortable talking about suicide involves the counselor first reflecting on their own thoughts, attitudes and potential biases around suicide. For example, is suicide preventable? Should clinicians use every means necessary to save a person’s life?

Common misconceptions about people who attempt suicide or who have suicidal thoughts are that they are attention-seeking, selfish, manipulative, weak, damaged, unpredictable, irrational, dangerous or immoral. Another common misconception is that asking someone if they are having thoughts of suicide will make them even more distressed. Language such as “tried to commit suicide” implies that suicide is a criminal act — similarly, the term “failed attempt” is insensitive. Counselors should understand how stigma can impact their client’s life. They should help explore how the client might experience overt prejudice and discrimination related to their suicide attempt/mental health or how they might internalize the stigma, resulting in shame, depression and lowered self-esteem. When clients recognize stigma as a problem residing in society rather than themselves, this may lessen its impact.


Why might a client not disclose a past suicide attempt to the counselor?

Many suicide attempt survivors have been exposed to coercive situations in health care, such as hospitalizations, welfare checks, interventions, restraints, incarcerations and institutionalizations, in which they felt a loss of control over their own lives and were traumatized. Many live in fear of that happening again. They may be concerned that a counselor will overreact, that the counselor will treat them differently after the disclosure or that the counselor will say that they are not qualified to work with them, especially if they disclose current ideation. Clients may detect subtle signs of discomfort from counselors around the topic of suicide and feel like counselors are overly concerned about liability rather than about helping them.


When and how should counselors initiate discussions about past suicide attempts?

I believe the topic should be broached with every client; counselors should not assume that any of their clients have or haven’t had a suicide attempt or thoughts of suicide. A counselor’s initiation of the topic communicates that the counselor is comfortable talking about suicide. Counselors should also initiate conversation regularly about suicidal ideation. Suicidal ideation is relatively common, but many people do not feel comfortable talking about it even with a counselor, so it is important to provide an opening for that discussion often. If the client says they’ve never experienced ideation or aren’t experiencing it right now, the counselor can let them know that if they ever do so in the future, the counselor is open to helping them work through it.

The counselor should be explicit and transparent about the protocol for addressing suicide, such as through a professional disclosure statement that includes a detailed description of how they will respond to disclosures related to suicide. Counselors might also wish to outline their previous experience, philosophies and techniques related to counseling clients with suicidal ideation on their website or disclosure statement.


How can a counselor help in guiding the client’s disclosures to others? What factors would a counselor consider in helping to create a disclosure strategy or plan?

Counselors can help clients consider the pros and cons of disclosing using motivational interviewing techniques, recognizing that there are many situations, such as at work, where it might be particularly risky to disclose. Individuals who are currently experiencing distress or ideation might have reasons or motivations for disclosing that center around gaining support, while others might wish to disclose so they can help other people or strengthen relationships.

Counselors can help clients recognize that disclosure is nuanced — the person they disclose to, the timing of the disclosure, method of disclosure, content of disclosure, can all be considered. Disclosure can be a selective and gradual process in which clients might share a small part of their mental health story with a selected person, and then decide whether to share further and more broadly. Some clients might tend to over-disclose, which can make others uncomfortable and reduce social support.

Clients can practice disclosure scripts (see sidebar below) with their counselors to become more comfortable and strategic about their disclosure. If clients have a disclosure-related goal in mind, they can tailor the disclosure to maximize benefits and reduce risks.

Counselors can help clients discern whether they are ready to disclose and how they might cope if a disclosure does not go as hoped or planned. Although talking about suicide reduces shame and helps people process their thoughts and feelings, it can also be anxiety-provoking and bring up difficult memories, thoughts and feelings. Clients may need help discerning which people/environments might be more supportive of disclosures.

Even when a disclosure goes “well,” it can have unintended consequences. For example, someone who engages in suicide advocacy work and then tells their story publicly may experience an extremely warm and positive response but become overwhelmed and have difficulty setting boundaries — at the expense of their own mental health — if peers come to them for help, support or resources. Counselors can help clients think through some of these unintended consequences as well.


Your JCD article mentions disclosures clients may make online or on social media. Are there any special considerations for such disclosures?

I actually recently submitted a paper to another journal that goes into more detail about benefits and risks of online disclosures. In short, perceived advantages of online disclosure are the anonymity it can provide, depending on the forum you are using, so people can disclose without being subject to stigma, coercive treatments or active rescues.

People often struggle most with suicidal ideation at night when they are alone and their support people, both professional and nonprofessional, are unavailable. The online world provides opportunities to connect with many people at all times of the day and night. Online support is also relevant for people with disabilities or other isolating situations that make getting support or interaction difficult. Some survivors talk about how having a large audience to share their story with is empowering and makes it possible to reach and impact others to save lives.

Disadvantages related to disclosure on social media include that it could be upsetting or triggering for others, especially if there are graphic descriptions of suicide methods. Of course, there is always the risk of trolling and online bullying in response to a disclosure, as well as having others not take the person who is disclosing seriously and perceiving them as attention-getting. Finally, there are obvious communication barriers in online communication such as the lack of body language, communication possibly not being in real time, and an inability to provide direct help in a crisis situation.

There are some folks in Australia who have done more work in this area and specifically focusing on young people (see


What “errors” or missteps should a counselor avoid in the discussion of disclosures?

Counselors may not realize how common it is for clients to have chronic suicidal ideation, including every day for years, but not have a plan or intent and to never talk about it.

Talking about suicide can be difficult for both the counselor and the client, and much like trauma work, counselors should be prepared for and have supervision around this.

Counselors should be prepared to engage in safety planning with their clients and have a safety plan template.


What should be included in safety planning or in a safety plan template? For example, do you mean a “road map” that the person agrees to follow if they are thinking about attempting suicide, stating who they will call, what they will say and where they will go to not be alone? Or a preemptive plan that might involve locking away medications or firearms outside of the home to reduce being able to complete suicide impulsively?

Yes, exactly as you describe. The safety plan is a road map and might include warning signs/triggers, coping strategies, reasons for living, specific plans for who to call or where to go, including professional and nonprofessional support, crisis line/emergency information, and self-restriction of lethal means. There are also apps that people can use for safety planning.


Lastly, how did the idea for this research come about?

I was doing research on the stigma surrounding suicide, and during interviews and focus groups, people talked about disclosure dilemmas and about not being comfortable talking about suicide with their therapists or counselors. I was fortunate to receive some funding to conduct the research on stigma and disclosure, so that was also very important.




ACA is proud to celebrate 100 years of publishing excellence with the Virtual Special Issue: JCD at 100 Volumes.



Scripting a disclosure: Conversation starters

Lindsay Sheehan notes that disclosure can be a selective and gradual process. Some examples of disclosure “conversation starters” are:

  • “I haven’t shared this with many people, but last year, I was struggling and tried to take my life. I’m doing much better, especially these past couple months, but I really value our friendship and thought it was important for you to know.”
  • “You know, I do have a history of my own mental health struggles, including being suicidal. If you want to talk with someone who’s been there, let me know.”
  • “I’m reaching out because I haven’t been feeling well lately, mentally, and just wanted to see if you had some time today to have lunch and talk with me a bit.”

In addition, if a client is choosing to disclose online, in a book or in a formal talk, they may want to include more details and make their script more like a “story” they can tell, Sheehan suggests.



Practice take-aways for counselors

  • Understand that although talking about suicide reduces shame, it can be anxiety-provoking and bring up difficult memories, thoughts and feelings for survivors.
  • To be more comfortable discussing suicide, first reflect on your own thoughts, attitudes and potential biases around it.
  • Help clients who wish to disclose outside of counseling to evaluate the pros and cons and to discern which people or environments are more likely to be supportive.
  • Offer to help the survivor practice a “disclosure script” to help them feel more comfortable and become more strategic about disclosing.
  • Engage in safety planning with survivors using a safety plan template.
  • Be explicit and transparent about the protocol you follow for addressing suicide, such as through a professional disclosure statement that includes a detailed description of how you will respond to disclosures related to suicide.



Joan M. Flynn is a senior content editor at the American Counseling Association and a contributing editor to Counseling Today. Contact her at


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

Creating meaningful and lasting change

Counseling Today April 13, 2022

The American Counseling Association’s Antiracism Commission grew out of an action plan developed to acknowledge and address issues of racism and discrimination within the counseling profession. The commission was established approximately one year ago, and its commissioners were appointed not long after that to begin discussing, evaluating and proposing actions to help ACA dismantle systemic and institutional barriers within the association and the profession as a whole.

ACA Antiracism Commission Chair Taunya Tinsley

Counseling Today recently contacted Taunya Tinsley, who chairs the commission, and asked her to respond to a series of questions and provide ACA members with an update on the work that she and her fellow commissioners are undertaking. Tinsley, a licensed professional counselor and national certified counselor, is the owner of Transitions Counseling Services LLC. She has previously served as president of the Association for Multicultural Counseling and Development and as a board member for the Association for Spiritual, Ethical and Religious Values in Counseling.  


For those who aren’t aware, can you briefly share some of the backstory of how and why the ACA Antiracism Commission was established?

Under the leadership of [ACA immediate past] President Sue Pressman, the Antiracism Task Force was birthed out of discussions related to an antiracism statement crafted by a team of volunteer members in the spring of 2020. After dialogue, discernment and wordsmithing, the ACA Governing Council issued a strong statement denouncing racism. The statement spoke out against the violence being experienced in Black and Brown communities. Many members who participated in the writing of the statement were dismayed by the number of police-related deaths of unarmed Black and Brown men. 

Once the motion to approve the statement was ratified, there was an immediate call for a task force to be created that would provide ACA with clear guidelines to be utilized to address this growing concern. The call to create a task force was thus realized and voted in by the Governing Council. The ACA leadership proving that they were listening to a cross section of members and volunteers set into motion a strategy geared toward creating a task force that would in return draft an action plan that would ultimately give life to the statement. 

The charge: It is our mission to develop an action plan by which counselors will 1) gain cultural self-awareness in relation to intrapersonal, interpersonal, community and global contexts, 2) enhance cultural competency and 3) provide evidence-based interventions and strategies that will empower counselors and others to facilitate action within local communities addressing racism and disparities that often lead to misunderstandings and/or violence. 

The council selected [ACA President] S. Kent Butler to chair a 31-member task force of representatives from across the ACA membership and leadership. Over the tenure of the Antiracism Task Force, members diligently provided an antiracism action plan. The ACA Antiracism Action Plan was composed of one short-term and one long-term goal from each designated work group. The action plan was provided to ACA staff to be vetted for sustainability and projected expenses. Once the staff completed that portion of the vetting process, the short- and long-term goals of the action plan were brought before the Financial Affairs Committee, followed by the Governing Council due process, for the eventual adoption of the actions. 

The action plan called for a commission to be formed to carry out the action plan and to further develop ACA’s response to systemic racism and discrimination within the association and throughout the counseling profession. The ACA’s first ever Antiracism Commission was established and formed in spring 2021 with goals to discuss, evaluate and propose actions that will guide ACA in breaking down systemic and institutional barriers that exist in the association and the counseling profession.

What is your role in chairing the commission?

My role in chairing the commission is to lead a very distinguished group of my colleagues to facilitate change around issues of racial injustice, systemic racism and how our association must address these challenges. 

As part of my role, it is important that I assist with ensuring the efficient functioning of the leadership team (i.e., commissioners) and communicating accurately and transparently the mission, vision and strategic goals of the team as well as the performance of the team. 

Furthermore, I ensure that the team members receive accurate, high-quality and timely information and reports to enable them to effectively monitor all aspects of the commission’s business as well as ACA’s Antiracism Action Plan. 

Finally, as the chair and coach of the team, it is important that I assist with ensuring that the commission and team members operate to the highest standards of integrity.

What is the commission charged with doing in the immediate future? How about over the long term?

As stated, the goal of the commission is to discuss, evaluate and propose actions that will guide ACA in breaking down systemic and institutional barriers that exist in the association and counseling profession. The commission has been charged with establishing a new organizational culture and assisting with reviewing policies and procedures that are antiracist. 

We are in an immediate and long-term position to create meaningful and lasting changes that reflect our moral integrity and values and that are consistent with [the core professional value stated in the ACA Code of Ethics of] “honoring diversity and embracing a multicultural approach in support of the worth, dignity, potential, and uniqueness of people within their social and cultural contexts,” specifically Black, Indigenous and people of color (BIPOC). 

As we foster ongoing, authentic conversations and dialogues about race, racism and anti-Blackness, it is our hope that we can begin to eradicate long-standing systemic racism within ACA and our profession and implement antiracist policies, procedures and trainings.

Why are you personally drawn to this work?

I am personally drawn and committed to this work! It is my core belief that I am required to act justly and to apply love, mercy and grace when providing a ministry of care and counseling. We are in a crucial period in the history of our nation and in our profession, and I am passionate about helping to acknowledge racial and ethnic disparities that impact the mental health, and add to the disparities, of BIPOC and other diverse populations. In addition to developing multiculturally and social justice-competent counselors, counselor educators and leaders, we must strategically address the historical context of systemic racism in our association, the profession and the world.

Do you expect to encounter resistance in the work you’re doing to confront racism and discrimination in the profession? If so, how will you handle that? What keeps you from getting discouraged?

Yes, the world is full of well-intentioned individuals. People with this mentality often operate from a closed-minded stance and make this crucial issue personal to them as opposed to fighting institutionalized racism, behaviors and the systemic barriers that block the pathway of those whom they claim have a right to equity and justice.

I will handle this by meeting people where they are. I will continue to assist them with increasing their self-awareness and worldview knowledge while developing antiracist skills, techniques and interventions.

Hope and faith keep me from getting discouraged!

What one thing do you want readers to walk away knowing about the ACA Antiracism Commission or racism and discrimination within the counseling profession?

The ACA board has approved an action plan to tackle issues of racism and discrimination within the association and throughout the counseling profession. In addition, the ACA Governing Council appropriated more than $200,000 to support these efforts and chart our path forward.

As [ACA CEO] Richard Yep has shared with the membership, the “Antiracism Commission is serving as a guidepost for the work to which ACA has committed. Appointed by ACA Immediate Past President Sue Pressman and current President S. Kent Butler, the commissioners were selected for their demonstrated commitment to promoting racial and social justice in every aspect of their work.” 

As the inaugural commission continues to grow, there will be opportunities for ACA members, divisions and branches to collaborate and partner to advance the counseling profession to ensure a safe, just and equitable space for our clients, colleagues and communities.


The 2021-2022 ACA antiracism commissioners are:

Taunya Tinsley, chair

Monica Band

LaTasha Hicks Becton

Shawn Spurgeon

Sam Steen

Ahmad Washington

Ebony White