Monthly Archives: September 2022

HBCU students take first place in ACA’s doctoral ethics competition

September 30, 2022

This award recognizes exceptional, demonstrable understanding of the ACA Code of Ethics, the foundation of ethical professional counseling practice. Each year, ACA honors top-ranking teams in both Masters and Doctoral level graduate degree programs.


Graduate Student Ethics Awards for Doctoral Degree Students

By Anitra Y. Powell, Sylvester R. Smith and Ulisha L. Fraser Reese

Department of Counseling, North Carolina A&T State University, Greensboro, North Carolina

Faculty Advisor: Shea Dunham


Prompt: James is a third year, full-time, doctoral student in a counselor education and supervision program. James identifies as a cisgender, white, male. He is providing weekly telehealth supervision to a master’s level internship student, Selena, who is enrolled in his Practicum course. Selena identifies as a Hispanic, female.

Selena has been receiving weekly supervision with James for the past 2 months and has planned to show a recording of a new client during their weekly scheduled supervision session. James asks Selena for verification that all informed consent documents and client’s permission were obtained to record the session. Selena verifies that she has used the informed consent intern forms from her practicum site and has obtained permission from the client. These forms disclosed that Selena was a student under supervision, but it did not specifically state what university Selena is enrolled in, or who her faculty supervisor was.

Selena shows the recording of the counseling session to James for review. In the recording, Selena’s client, Henry, is discussing a recent affair that he had and how he plans on leaving his spouse in the near future. James is visibly upset as he watches the recording with Selena. James begins to give Selena advice on how she needs to strongly encourage the client to tell their spouse about the affair. Selena does not feel comfortable with this guidance from the supervisor but follows through with the recommendation due to feeling pressure from her supervisor.

Fifteen minutes prior to their next scheduled supervision session, James informs Selena that his account has not been working properly and states that he will FaceTime her instead for supervision just this once, because he does not want to miss their weekly supervision. During this supervision session, James then focuses only on this case and continues to give advice on how Selena should be protecting the client’s spouse in this situation. Selena is uncomfortable with this direction and the attention that James is giving to this case. She decides to consult with her site supervisor who encourages her to focus on the client’s perspective. In the next session with the client, he stated that he is apprehensive about how his spouse and in-laws will treat him if he discloses the affair. In this meeting Selena finds out that James is the father-in-law of her client. Selena is now unsure how to approach this situation.


Abstract: Defining ethics of clinical supervision as an area of specialization involving supervisor, supervisee, and the client is key in ethical decision making. The essay discusses areas of responsibility, informed consent, values, and decision making, ethics and technology, ethics and diversity/multiculturalism, responsibility to colleagues, confidentiality, privacy, due process, and competence. The authors further explain the ethical violations and the legal issues that arise while providing strategies for their prevention. Lastly, the essay applies the Tarvydas Integrative Decision-Making Model for formulating decision making to avoid ethical violations down to enforcement; while seeking to give insight, adding to a collaborative relationship, and serve as competent stakeholders and gatekeepers for best practice (Cottone & Tarvydas, 2006).


Doctoral Prompt and Tarvydas Integrative Decision-Making Model

The prompt describes James (cisgender, white male) a third year, full-time doctoral student in the role of educator and supervisor to Selena (master’s level Hispanic female student enrolled in her practicum) for over 2 months. All preliminary documents such as informed consent appears to be verified via her practicum site to show telecommunication recordings of her sessions for supervision; however, documents did not specify her university or faculty supervisor invalidating the documentation. Consents should discuss the nature of the procedure, risk and benefits of the procedure, reasonable alternatives, risk and benefits of alternatives, and assessment of the consumers understanding of the elements of the consent form, confidentiality, and contacts.
James and Selena either out of incognizance or oversite proceed their course of action and inevitably confronts a dilemma. James witnesses his son-in-law’s infidelity in the video where he confronts his personal values with his ethical obligations. Selena is clearly uncomfortable as noted by her confronting her site supervisor. James advances a line of decisions that continues to blur his objectivity as a supervisor essentially harming the client, supervisee, distorting his role, and compromising the code of ethics.
The authors will use the Tarvydas Integrative Decision-Making Model to explore our prompt and reach a resolution of the present prompt. The model is chosen because it blends and reflects on personal and moral sensitivity of persons impacted, respects the philosophy of the American Counseling Association (ACA) profession, gauges objectivity and perspectives stakeholders (Cottone & Tarvydas, 2006). It incorporates multiple contexts such as social, cultural, political, legal, and economic factors while also analyzing the efficiency and competence of ethical considerations (Cottone & Tarvydas, 2006).

Awareness and Fact-Finding

The purpose of the American Counseling Association Code of Ethics (ACA, 2014) is to have a written understanding to help counselors with the process of analyzing limits and competing interest. This agreed upon “handbook” facilitates for the counseling professional ways to help promote the welfare of the consumer, make sure we are “doing no harm,” practicing with competence, respecting confidentiality and privacy, acting in an ethical and responsible way, and avoiding exploitation of consumers (ACA, 2014).
As we engage in the fact-finding process, we consider reasonable sequences of actions on all involved in the dilemma to help with analyzing thoughts, feelings, expectations, motivations, concerns, the reaction on others, as well as ourselves as counselors. We reflect our ethics and professional etiquette while taking into consideration basic consumer principles: do no harm, beneficence, nonmaleficence, veracity, fidelity, justice, and autonomy (ACA, 2014). These principles are pillars in counseling and provide a fair and balance weighing to situations. It is necessary that as supervisor and supervisee work to enhance the lifespan of the client while considering multicultural lens, diversity approaches, social justice advocacy; together, safeguard counseling, counseling relationship, and demonstrating competence in an ethical manner (ACA, 2014).

Diversity and Multiculturalism

Understanding cultural differences and diversity amongst professionals is essential in respecting individuals’ cultural mores and gaining greater insight on an individual’s professional identity. Belief systems can assist with identifying how individuals are shaped and influenced in which create ideologies that help interpret our daily reality (Smith, 1966). Social norms within the Hispanic culture emphasize the importance of both verbal and nonverbal communication (Smith, 1966). This could have assisted with the interpersonal relationship between the supervisor and supervisee.
In reviewing the 2014 ACA Code of Ethics many ethical concerns were observed. However, the most prevalent are listed below with justifications:

  • A.1.a. Client Welfare – Although James is aware, he knows Selena’s client upon reviewing the video recording, he pushes Selena to provide guidance to the client based off his own personal feelings and agenda. Therefore, neglecting the best interest of the client and possibly causing an unhealthy relationship between Selena and the client and Selena and himself.
  • A.2.a. Informed Consent – James only verbally verified Selena’s informed consent form, leaving gaps in the documentation process. Counselors have an obligation to review this form in writing and verbally with the client. This hindered the client’s freedom of choice whether to enter into or remain in the counseling relationship. If provided with the adequate information such as Selena’s faculty supervisor, the client would have been aware that he was related to Selena’s supervisor.
  • A.4.a. Avoiding Harm – Once James was aware that the client was his relative, he should have removed himself from the counseling process to prevent bias and imposing his personal beliefs onto Selena. James also created discomfort in the supervisor/supervisee relationship and caused Selena to seek additional support from her site supervisor.
  • A.4.b. Personal Values – When James met with Selena for supervision, he only focused on the current ethical dilemma. James imposed his personal opinion and provided unsolicited advice on how Selena should assist the client which was opposite of Selena’s views.
  • A.5.d. Friends or Family Members – James was aware when watching the recorded session that the client was his daughter’s husband and his supervision direction to Selena and body language towards the session convey how he is unable to remain objective.
  • B.1.b. Respect for Privacy – James knew before finishing the recorded session that the client was his son-in-law, however watched it to the end. At this time James violated the client’s privacy and watching the entire recording was only for his personal benefit.
  • B.1.c. Respect for confidentiality – Selena shared the recorded session of her client to her supervisor without appropriate consent.
  • B.3.e. Transmitting Confidential Information – James should not have conducted supervision through an unsecured method such as FaceTime when his account was not working properly. James should have additional consents in place to use alternative secure method and a reschedule policy.
  • B.6.d. Permission to Observe – Although Selena received permission to record the session, no permission was received for any other person to observe the counseling session.
  • C.2.e. Consultation on Ethical Obligations – While Selena sought out assistance from her site supervisor after her weekly supervision meeting, Selena should have considered the fact she was unconformable when receiving guidance from her supervisor prior to and would have known to consult with other counselors as per the ACA Code of ethics.
  • F.11.d. Multicultural Competence — In Hispanic traditional patriarchal structure women are expected to be submissive to older male adults, therefore James should have been more cognizant of this. Although Selena was uncomfortable with James’ advice, she still followed through with telling the client. If Selena understood the body language queues, she would have noticed her supervisor was visibly upset after watching the recorded session. Selena should have used a cultural developmental model such as A.S.Ruiz (1990) to be more aware of Western society and cultural barriers. This could have assisted in her understanding of cultural identity, forced assimilation and freedom to advocate for her client (Sue & Sue, 2008).

Distance Counseling and Technology

The Licensed Clinical Mental Health Counselors (LCMHC) Act NC GS Article 24 (2019) surrounding counseling via technology are centered around protecting the client. These laws do not specify system qualifications in distance counseling except services must be provided via an encryption platform (NCBLCMHC, 2019, Article 24). James recognized an issue with his secure platform before his meeting with his supervisee. However, James proceeded to use FaceTime as a platform to meet with Selena for supervision. James did not consider ethical and legal ramifications for this change in their confidential platform North Carolina General Statutes does not identify specific platforms in which counselors can provide distance counseling (NCBLCMHC, 2019, Article 24). When technology is utilized as a part of counseling services it has to be maintained and regular maintenance checks are required (H.5.c.). One focus of the law is encryption of technology platforms (NCBLCMHC, 2019, Article 24). Encryption serves as a safeguard against breaches in the confidentiality (H.2.b.). FaceTime does not meet the qualifications as an encrypted platform and should not have been used for this meeting. It is the responsibility of James and Selena to protect their client’s information (H.5.a.).
In addition to encryption of technology platforms the General Statutes stresses the importance of educating the client in the ramifications and procedures of participating in counseling via the internet (NCBLCMHC, 2019, Article 24). Safeguarding information surrounding the encrypted platform address how the client’s records will be maintained over time (H.2.b). During the initial meeting with the client to obtain informed consent the counselor should educate the client and include in their handbook how session records will be preserved and disclosed (H.5.c.). It would have been best ethical practice for James and Selena to provide the client with the details on how recorded sessions are shared and preserved through Client education on the use of technology details how long records are saved and consist of permission from the client on exactly who this information can be disclosed to (H.2.a.).
James and Selena are obligated to follow the laws of practicing counseling at the state level when utilizing technology for counseling services (NCBLCMHC, 2019, Article 24). The implications of the use of a session recording and platforms should have been addressed through their supervision and with the client (H.1.b.). James did not maintain professional boundaries once he viewed the recording and saw his son-in-law in session with Selena (H.4.a.). It was an inappropriate use of technology when did not disclose his dual relationship with Henry but viewed the recording as means to direct Selena on how to get the affair shared with his daughter (I.1.c.).

Reflective Analysis

Due to a dual relationship, (A.5.d.) James interrupted his ability to be an objective supervisor (A.4.a., A.6.d.). James’ personal values and loyalties ran counter to the welfare of the client and his ability to be impartial as a supervisor (A.4.a). James should have consulted with his colleagues (B.7.a. B.7.b.) in efforts to eliminate nonmaleficence. James’ blind spot and personal bias for his daughter created competing loyalties.
James unwittingly engages in cultural marginalization and negates his role as a supervisor. The dual relationship forced him to become an arbitrator playing favorites rather than delivering best ethical practice in a culturally sensitive and objective manner with respect to the supervisee and client (A.6., A.6.a.). Cultural competence amongst professionals is essential in respecting individuals’ cultural differences within their social and cultural contexts (A.4.b.).
In the prompt, James never accounts for the systematic influence that his role as a white male supervisor plays in the supervisory role at the university level or within society (A.7.). He never takes account of his personal or professional position in the hierarchy and how it contrasts with her cultural foundations. He never acknowledges the implications of Selena’s family structures, sex-role expectations, acculturation conflicts, educational characteristics, linguistic context, intrapsychic issues of society such as suspiciousness of outside authorities (Sue & Sue, 2008). James in the prompt never allow Selena to state her own words to the problem as she sees them. Also, he does not evaluate whether Selena has a grasp of her responsibilities as a supervisee. It seems James is oblivious to the power differential that exist between them on multiple levels (C.2.d.).

Planning and Executing the Selected Course of Action

It would benefit James to discuss with his university ways to manage confidentiality, privacy, video (G.5.) consent at various stages to prevent further intrusion into matters that may challenge his own personal biases and cause harm to the client. It would help if James utilized case consultation to discuss and review documentation to respect privacy, protect the client’s identity and to avoid undue invasion of privacy. James then can monitor the effectiveness of the case and provide reasonable steps to evaluate before viewing the videos (G.5.). Video consent and review of documents could have been reexamined to make sure all pertinent information was in place to protect the identity of the client.
In becoming culturally competent it is feasible for James to start exploring his own historical roots, beliefs, and values. It would benefit him to learn about diverse cultures, interact with diverse groups, attend diverse focus conferences, and talk with his university about his blind spots and biases. Cross-cultural competency training is a preferred course of action to help him gain knowledge of supervision models to learn sensitive interventions and strategies to heighten awareness of culturally different populations.
Suspending James of his role as a supervisor until he can receive evidence base training in a conceptual model of supervision is recommended. James showed critical issues in supervision around areas of competence, theoretical identity, respect for individual and cultural differences, direction and purpose of goals, personal meaning and motivation for the supervisee, and professional values (Bernard & Goodyear, 2018). James never demonstrated he understood Selena’s developmental level within the supervisory process. Selena supervision would have been enhanced by integrating counseling theory, academic coursework, overlapping steps of counseling principles in the parameters of supervisee and supervisor related issues such as professional disclosure, tracking development, and evaluation statements for feedback and parallel process (Bernard & Goodyear, 2018).

Concluding Thoughts

The counseling profession can often be complex and intricate. Therefore, having a set of rules and expectations that can be followed for not only ethical obligations, but also ethical decision making is of the upmost importance. While the mission of the 2014 ACA Code of Ethics emphasizes the importance of professional counselors’ development and advancement of the counseling professional, it also highlights how professionals should uphold professional values that primarily safeguard the client’s interest.
In maintaining the standards of the profession supervision is needed. Supervision is an intervention with its own models and techniques. Training is structured in a progressive way so supervisee can development from a novice to a professional with skills acquired along the path (Bernard & Goodyear, 2018). It is wholly the supervisor and supervisee task to support the developmental stages by scaffolding prior knowledge and skills (Bernard & Goodyear, 2018). As a competent supervisor or aspiring supervisor, it is important to understand the clinical supervision domains of client’s and supervisee’s supervision to help with the overall orientation of the counseling process (Bernard & Goodyear, 2018). Committing to competency-based supervision recognizes the importance goals being served by clients, supervisees, supervisors, accredited programs, the professions, and society at large.

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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.

What’s new with the DSM-5-TR?

By Aaron L. Norton September 29, 2022

Diagnostic and Statistical Manual of Mental Disorders, image via Flickr

Image via Flickr

Traditionally, our holistic emphasis on a wellness model as opposed to a medical model has been touted as a unique aspect of our professional identity as counselors. Many counselors feel more comfortable with humanistic, existentialist and postmodern theories that seem to clash with the medical model. The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA), is one of the most salient symbols of that model, so why should we care about it?

The ability to diagnose using a medical model is integral to much of what we want for our profession, such as Medicare parity, licensure portability, fair and equal access to psychological tests, and integrated care. For this reason, counseling associations have advocated relentlessly for state legislators to include the diagnosis of mental disorders in the scope of practice of licensed counselors.

According to the National Conference of State Legislature’s Scope of Practice Policy website, 36 states and U.S. territories specifically include diagnosis in behavioral health providers’ scope of practice, and an additional 19 states and U.S. territories neither empower nor prohibit counselors from diagnosis.

This diagnostic power conferred by the state comes with great responsibility, and the 2014 ACA Code of Ethics calls on counselors to diagnose properly (see Standard E.5.a.). The DSM is the most widely recognized diagnostic system for mental disorders. Although the DSM is imperfect and flawed, and there are alternative ways of conceptualizing mental health, it is nonetheless important for counselors to have a working knowledge of it.

In the following sections, I explore some common questions counselors have about the latest edition, the DSM-5-TR, which was published in May.


Why DSM-5-TR? Why not DSM-6?

The “TR” stands for “text revision.” Essentially, this means that APA intended to update the research components of the text and clarify some of the diagnostic criteria, but there were not enough advances in the field to support the need for the creation, revision and elimination of multiple disorders. The DSM-5 was published in 2013, and the research and statistical data contained in the manual are now outdated. The DSM-5-TR provides updated data consistent with research published since 2013.

How was DSM-5-TR developed? Were any counselors involved?

The DSM-5-TR revision started in the spring of 2019, and the final version was published in March. The DSM-5-TR specifically includes counselors in a list of professionals the text was written for, but were any counselors involved in the revision itself?

Over 200 multidisciplinary subject matter experts were involved in the revision — 64% psychiatrists, 30% psychologists and just 6% “other health professionals.” The text states that “many professional and educational groups were involved in this development and testing of DSM-5, including physicians, psychologists, social workers, nurses, counselors, epidemiologists, statisticians, neuroscientists, and neuropsychologists.” It is unclear how many counselors were involved in the revision, but it does not appear that many were.

Three primary groups were involved in the revision, including the DSM-5 Task Force, DSM Steering Committee and Revision Subcommittee. Experts were divided into 20 disorder review groups, each headed by a section editor. Four cross-cutting review groups (culture, sex and gender, suicide, and forensic) recommended updates throughout the text. Revisions were approved by the APA Board of Trustees, and public feedback was solicited and considered.

Are there any new disorders in DSM-5-TR?

There is only one new disorder in the DSM-5-TR: prolonged grief disorder. It is an updated version of a disorder that we saw in Section III of the DSM-5 (i.e., the section that describes conditions being considered for future editions of the DSM) called persistent complex bereavement disorder. It can now be found in Section II of the DSM-5-TR in the “Trauma and Stressor-Related Disorders” chapter because it is considered a reaction to a trauma or stressor.

The diagnosis of prolonged grief disorder is conceptualized as an intense longing or yearning, often with intense sorrow and emotional pain, for a deceased person close to the bereaved client, accompanied by preoccupation with thoughts or memories of the deceased person. It can only be applied if:

  • the deceased person died more than 12 months ago (for adults) or 6 months ago (for children and adolescents);
  • the client has a persistent grief response present on most days “to a clinically significant degree” (e.g., intense longing/yearning for the deceased, preoccupation with thoughts and memories of the deceased);
  • at least three of eight specified symptoms (i.e., identity disruption, marked sense of disbelief about the death, avoidance of reminders about the death, intense emotional pain, difficulty reintegrating into relationships and activities, emotional numbness, feeling that life is meaningless, and intense loneliness) have been present most days to a clinically significant degree;
  • symptoms cause clinically significant impairment or distress;
  • duration and severity of bereavement clearly exceed social, cultural or religious norms; and
  • the disturbance is not better explained by another disorder or the effects of one or more substances.

Its prevalence is unknown, but the DSM-5-TR references a rate of 9.8% with little clarity about that statistic (i.e., whether it is cross-sectional or a lifetime or perhaps 12-month prevalence rate).

Critics of the new disorder voice concerns that grief is being pathologized. Proponents, however, point out that only a small percentage of bereaved clients would meet the diagnostic criteria, the criteria clearly represent an unusual response to grief, individuals who meet criteria respond to specialized therapeutic approaches (i.e., prolonged grief disorder therapy) while their peers with uncomplicated bereavement require less intervention, and those individuals need professional help that might be difficult to access without the construct of a diagnosis.

What about racism, discrimination and cultural considerations? Anything new?

A cross-cutting review committee on cultural issues consisting of 19 U.S. and international-based experts in cultural psychiatry, psychology, and anthropology and an ethnoracial equity and inclusion work group of 10 mental health practitioners from diverse ethnic and racialized backgrounds with expertise in disparity-reduction practices were involved in the development of the DSM-5-TR. Because of their work, several semantic changes were made to the text, including the following:

  • The terms “race” and “racial” were replaced by “racialized” to highlight the socially constructed nature of race.
  • The term “ethnoracial” was used to denote U.S. Census Bureau categories Hispanic, white, or African American that combine ethnic and racialized identifiers.
  • The terms “minority” and “non-white” were avoided, as these terms infer that white is hierarchical to other racial identities, thus perpetuating social hierarchies.
  • The term “Latinx” replaced Latino/Latina in an effort to be sensitive to individuals who do not identify with binary gender markers. This revision may be lauded by transgender advocates but could also be frustrating to many Hispanic Americans who view the term Latinx as a form of colonialist intrusion into their language. Polling data from the Pew Research Center in December 2019 revealed that 76% of Hispanic adults had never heard of the term Latinx, 20% had heard it but didn’t use it, and only 3% used the term. According to an article published in Politico in December 2021, nearly half of Hispanic Americans view the term Latinx as offensive, so the two largest Spanish-speaking television networks in the country opted to replace Latinx with Latino and Latina. In an article published in The Conversation in September, Melissa Ochoa, an assistant professor of women’s and gender studies, reported that the governments of Argentina and Spain released public statements banning use of the term Latinx in July, and the term “Latine” has emerged as a more suitable gender-neutral term to replace the terms Latino and Latina because it does not violate rules of the Spanish language. It will be interesting to see whether Latinx or Latine becomes more widely accepted with time.
  • The term “Caucasian” was replaced with “non-Latinx white.”
  • Throughout the DSM-5-TR, prevalence data on specific ethnoracial groups has been included when possible.

What other disorder-related changes were made?

Some relatively minor changes (most of which are semantic) were made for a few other disorders. In my opinion, one of the most important changes involves the creation of diagnostic codes for suicidal behavior and nonsuicidal self-injury, which will allow for more effective tracking of these conditions. Other changes include the following:

  • The DSM-5 contained two sets of codes next to each disorder: the International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes. Because all U.S. health care providers regulated by the Health Insurance Portability and Accountability Act were supposed to transition to ICD-10 codes on Oct. 1, 2015, the ICD-9 codes have all been removed from the text.
  • The Criterion A phrase “as manifested by the following” for autism spectrum disorder was replaced with “as manifested by all of the following” to maintain high diagnostic threshold.
  • Disruptive mood dysregulation disorder was clarified as diagnosable between ages 6 and 18.
  • The note “witnessing does not include events that are witnessed only in electronic media, television, movies, or pictures” in Criterion A2 of posttraumatic stress disorder was removed for children 6 years and younger due to redundancy.
  • The phrase “with relatively intact reality testing” was removed from attenuated psychosis syndrome, and symptoms were described more accurately.
  • A new set of severity descriptors was added to bipolar disorder.
  • The phrase “reduced orientation to the environment” for delirium was replaced with “accompanied by reduced awareness of the environment.”
  • Conversion disorder was renamed as functional neurological symptom disorder.
  • Several terms related to gender dysphoria were altered. Specifically, “desired gender” was replaced with “experienced gender,” “cross-sex medical procedure” was replaced with “gender affirming medical procedure,” “cross-sex hormone treatment” was replaced with “gender affirming hormone treatment,” “natal male” was replaced with “individual assigned male at birth,” “natal female” was replaced with “individual assigned female at birth,” and “differences in sex development” was noted as an alternative term for “disorders of sex development.”
  • For intellectual disorder, renamed intellectual developmental disorder, clarification was provided that although one should not be bound narrowly to the 65-75 IQ score range, the diagnosis would not be appropriate for those with substantially higher IQ scores.
  • For major depressive disorder, the Criterion D phrasing “The occurrence of the major depressive episode is not better explained by schizoaf­fective disorder” was changed to “At least one major depressive episode is not better explained by schizoaffective disorder and is not superimposed on schizophrenia.”
  • Narcolepsy subtypes were revised to harmonize with the third edition of the International Classification of Sleep Disorders and ICD-11.
  • Olfactory reference disorder (olfactory reference syndrome), which the DSM-5 referred to as “Jikoshu-kyofu,” replaced other specified obsessive-compulsive and related disorder to dispel the misunderstanding that the disorder only occurs in Japan.
  • In the third example of other specified bipolar and related disorder, the line “if this occurs in an individual with an established diagnosis of persistent depressive disorder (dysthymia), both diagnoses can be concurrently applied during the periods when the full criteria for a hypomanic episode are met” was deleted because of a conflict with Criterion E for persistent depressive disorder, which states in part that “there has never been a manic episode or a hypomanic episode.”
  • Manic episode superimposed on a psychotic disorder was added as the fifth example of other specified bipolar and related disorder with the intention of being used when other psychotic disorders from the exclusion criterion for Bipolar I and Bipolar II disorders (i.e., schizophrenia, delusional disorder, psychotic disorder not otherwise specified) do not have mood episodes as part of their diagnostic criteria, leaving no way for the mood episodes to be accounted for by the diagnosis.
  • The DSM-5 example of “attenuated delirium syndrome” under other specified delirium was replaced with “subsyndromal delirium.”
  • “Major depressive episode superimposed” was added as a fourth example of other specified depressive disorder for use when a major depressive episode occurs concurrent with a psychotic disorder that does not have mood episodes as part of its diagnostic criteria.
  • The sentence “individuals with atypical anorexia nervosa may experience many of the physiological complications associated with anorexia nervosa” was added to the description of the atypical anorexia nervosa example of other specified feeding or eating disorder to clarify that the presence of physiological consequences during presentation does not mean that the diagnosis is the (typical) anorexia nervosa.
  • In the fourth example of other specified schizophrenia spectrum and other psychotic disorder, the phrase “delusional symptoms in partner of individual with delusional disorder” was changed to “delusional symptoms in the context of relationship with an individual with prominent delusions” to clarify that (a) the “inducer” does not need to have a romantic relationship with the patient and (b) the “inducer” does not necessarily need to have a delusional disorder.
  • For persistent depressive disorder, the parenthetical “dysthymia” was removed to avoid confusion with DSM-IV-TR diagnosis of dysthymic disorder, which could not be diagnosed if the individual had ever met criteria for a major depressive disorder. Additionally, all specifiers were removed except anxious distress and atypical features.
  • The parenthetical “social phobia” in social anxiety disorder was removed.
  • For substance/medication-induced bipolar and related disorder, the DSM-5 Criterion A terminology “prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by elevated, expansive, or irritable mood, with or without depressed mood” was changed to “prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by abnormally elevated, expansive, or irritable mood and abnormally increased activity or energy.” Additionally, the DSM-5 Criterion B1 phrase “developed during or soon after substance intoxication or withdrawal or after exposure to a medication” was changed to “developed during or soon after substance intoxication or withdrawal or after exposure to or withdrawal from a medication.”

What changes were made to Section III in DSM-5-TR?

Section III of the DSM-5-TR contains emerging measures and models relevant to the diagnosis and conceptualization of mental disorders. Specifically, it contains several free assessment measures that counselors can use in clinical practice, additional information on cultural considerations for diagnosis, an alternative model for personality disorders, and conditions that are being considered for adoption in future revisions of the DSM. Changes made to Section III include the following:

  • Male and female checkboxes were removed from all assessment measures in a shift away from binary gender identification.
  • Instructions in the Clinician-Rated Dimensions of Psychosis Symptom Severity measure were edited to mirror new severity specifiers for psychotic disorders added to Section II.
  • Scoring instructions for the World Health Organization Disability Assessment Schedule 2.0 were clarified.
  • Terms such as “culture,” “race” and “ethnicity” were revised in the Cultural Formulation Interview. 

If I already own the DSM-5, do I need to purchase the DSM-5-TR?

Given that the DSM-5-TR contains a new diagnosis and updated research, I recommend obtaining a new copy. However, if you are not concerned with prolonged grief disorder and you do not use the statistical information in the DSM, then you may not have a sense of urgency to purchase the new edition.

Where can I go to learn more?

Here are some resources where you can learn more about the DSM-5-TR:



Aaron L. NortonAaron L. Norton is the executive director of the National Board of Forensic Evaluators, a visiting instructor at the University of South Florida’s Department of Mental Health Law & Policy, and the southern regional director for the American Mental Health Counselors Association.





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.

Finding hope after surviving suicide

By Lisa R. Rhodes September 27, 2022


Rick Strait, a licensed professional counselor (LPC) in Southeast, Missouri, tried to take his life on his 20th birthday. It was July 18, 1993, and Strait, then a lance corporal in the Marine Corps, spent the morning at the beach with his wife and son.

“That [trip] was kinda my goodbye to her and my son,” Strait says. “She didn’t know what I was thinking.”

When the family returned home, Strait attempted to take his own life by suicide, but his wife interrupted him. After seeing how distraught his wife was from the experience, Strait made the decision to never try to take his life again. “And I never did,” he says. “I honored that.” 

Strait, the substance use division director and suicide prevention coordinator at the Community Counseling Center in Cape Girardeau, Missouri, says the combination of the death of his younger brother in a car accident only a few months earlier that year and ongoing family struggles became too difficult for him to handle. 

“I didn’t know how to move forward,” Strait says, noting that the pain and sadness he felt about his brother’s death was so deep that he didn’t know how to communicate his feelings to family or friends. “I did not want to talk to my parents about it because they were also struggling. I didn’t want to become a burden, so I kept it to myself.”

Strait says he also questioned his purpose in life and felt the weight of survivor’s guilt.

“I thought, ‘Why did he die and I’m still here?’” Strait recalls. “I took a lot of responsibility for my brother’s death, even though I had nothing to do with it. I was [living] in another state. I still felt I should have been there for my little brother.”

Strait remained silent about the attempt on his life for more than 20 years. He says shame and embarrassment kept him from seeking psychotherapy. But in 2016, he told his parents and his children and started treatment.

“Most people, they really don’t want to die; they just want the pain to end,” Strait adds. 

According to the counselors interviewed for this article, applying cognitive behavior therapy (CBT) and strengths-based therapeutic approaches can help suicide attempt survivors learn the skills to cope with the complexities of life and find hope for the future. (The term “suicide attempt survivor” refers to a person who has attempted suicide and lived, whereas the term “suicide loss survivor” refers to a person who has lost someone who died by suicide.)

Strait says that with the right support and professional help, suicide attempt survivors “can get through” the aftermath of a suicide crisis.

Safety first

Suicide prevention and reducing the rate of suicide have been important goals for many mental health organizations for decades. Although suicide is a leading cause of death in the United States, with 45,979 suicides in 2020, according to the Centers for Disease Control and Prevention (CDC), the number of people who think about or attempt suicide is even higher. The CDC reported that in 2020, an estimated 12.2 million Americans seriously thought about suicide, 3.2 million planned a suicide attempt and 1.2 million attempted suicide.

According to the 2018 article “Suicide risk and mental disorders” published in the International Journal of Environmental Research and Public Health, most suicides are related to psychiatric disease, with depression, substance use disorders and psychosis being the most relevant risk factors. The article also notes, however, that most people with mental health disorders will not die by suicide. 

Tammi Ginsberg, a licensed clinical professional counselor with a private practice in Woodsboro, Maryland, says suicide attempt survivors are usually referred to counseling after being taken to the emergency room following the crisis and undergoing a psychiatric evaluation. A psychiatric evaluation is often necessary to determine if there’s an underlying mental health issue that needs to be addressed, she explains. Suicide attempt survivors may also meet with a therapist and case manager at the hospital to determine if inpatient or outpatient care is required and what community resources for therapeutic treatment are available.

The counselors interviewed for this article say the immediate short-term goals of therapy are to establish a relationship based on trust and to ensure the client’s safety by creating a safety/crisis plan. Meeting these clients “where they are” in their recovery journey and bringing empathy to the therapeutic relationship are effective ways to establish trust, says Trish Torzala, an LPC at Stress Management & Mental Health Clinics in their Waukesha, Wisconsin, office. 

Strait, who is also a part-time adjunct faculty member at the Zero Suicide Institute in Waltham, Massachusetts, and a board member of United Suicide Survivors International, advises counselors to be genuine and to treat clients with respect. He says it is also important to affirm them for sharing their suicidal thoughts or the circumstances surrounding the attempt.

“It takes a lot of bravery and vulnerability to share something so intimate,” he says.

Ginsberg, president of the Maryland chapter of the American Foundation for Suicide Prevention, recommends counselors practice “active listening” — listening without interruption, judgment, opinions or solutions — with clients. This type of listening gives clients the space to “let you know what’s really going on,” she says. 

“A lot of times, [these clients] just want somebody to listen to them. They don’t want you to tell them how to fix it. They don’t want you to tell them that everything is going to be OK,” Ginsberg continues. “They don’t want you to tell them all they have to live for. They just want you to listen.”

And by being an active listener, counselors can help decrease the chance of clients making another attempt because “they feel heard, they feel seen, they feel normalized and they don’t feel alone,” she adds.

In regard to creating a safety/crisis plan, Strait and other counselors interviewed recommend the Stanley-Brown Safety Planning Intervention, developed by psychologists Barbara Stanley and Gregory Brown. Counselors and clients can use this tool collaboratively in session to create an intervention plan aimed at reducing the client’s risk for suicide. A safety/crisis plan is particularly important for suicide attempt survivors because, according to the Harvard T.H. Chan School of Public Health, a “history of suicide attempt is one of the strongest risk factors for suicide.” 

The Stanley-Brown Safety Planning Intervention includes having clients identify possible warning signs for suicide, proposed coping strategies, people they can contact for help during a crisis, professionals contacts or organizations that can provide care and support, and guidelines to keep them safe (for example, the removal of firearms from a client’s home).

Dealing with the distress 

After counselors establish trust and work with clients to create a safety/crisis plan, they can then help their clients examine the unique factors that may have led to the suicide attempt. A family history of suicide, mental health disorders or substance use disorders can contribute to the reasons why people try to end their lives. However, according to the counselors interviewed for this article, these factors can often be combined with a painful or significant life event, either past or present, that seems insurmountable. 

These life events could include, for example, the breakup of a relationship or marriage, financial or legal problems, childhood trauma or other forms of unresolved trauma, or the death of a loved one. The weight of this psychological angst often results in questions about the meaning of life and the rumination of negative thoughts and feelings, which, the counselors interviewed for this article say, can linger in the aftermath of a suicide attempt. 

Támara Hill, an LPC and owner of Anchored Child & Family Counseling in Monroeville, Pennsylvania, says many suicide attempt survivors go through existential anxiety and feel uncomfortable in their lives. Some suicide attempt survivors, for example, say they can’t find their purpose or meaning in life or that they can’t see their own personal value or worth. “They sink under their own negative thoughts about life and themselves,” she notes. 

Torzala, who specializes in suicide prevention, has found that some clients express feelings of shame and anger for surviving an attempt. Their survival makes them feel like a failure, she says. When discussing their suicide attempt, some clients have told her, “I tried this and it didn’t work. What’s wrong with me?” or “I can’t even get that right.”

Ginsberg, who has counseled suicide attempt survivors and their families for 15 years, says she has heard similar comments from clients. Some have told her, “I’m disappointed that I’m still here.” 

Clients also express feelings of hopelessness and negative beliefs about the self after a suicide attempt, says John Sommers-Flanagan, a professor of counseling at the University of Montana. For example, clients may say, “I’m a bad person. I’m worthless. No one will ever love me.”

In addition, suicide attempt survivors may have difficulties solving problems in general and problems related to their suicidal impulses in particular, Sommers-Flanagan notes. “They have trouble believing that there are any solutions or alternatives that will make them feel better,” he says. 

The emotional distress that these clients experience both before and after a suicide attempt can feel so immense that they often feel defeated and trapped, explains Sommers-Flanagan, a member of the American Counseling Association. 

Clients often struggle to see any options beyond their crisis and only want to escape the unbearable pain, Torzala adds, and the only option they can see is to end their lives.

Addressing negative thoughts 

According to Hill and Torzala, suicide attempt survivors often struggle with cognitive distortions and emotional dysregulation. Ginsberg says suicide attempt survivors can also carry unresolved wounds from childhood trauma that impact their mental health. These counselors use  CBT techniques to help clients process negative thoughts, gain insight into their emotions and come to terms with childhood wounds.

Hill, author of Understanding and Helping Suicidal Teens: Therapeutic Strategies for Parents and Teachers From a Trauma Therapist, once used the CBT triangle to help a female client understand the connection between the thoughts, feelings and emotions that led to her suicide attempt. The goal was to help the client process and reframe her thoughts and feelings to develop healthier behaviors. 

Hill asked the client to journal the thoughts and feelings she had leading up to her suicide attempt. She then reviewed the journal in session with the client and pointed out the client’s negative self-talk and explained the cognitive process — the connections between her thoughts and feelings — that led to her suicidal behavior. 

Hill, who is also a board-certified trauma therapist, provides an example of this cognitive process. Someone may engage in negative self-talk such as “I’m never going to be loved,” “I’m never going to be good enough” or “I’m a failure in life.” This talk, she says, may then lead to suicidal thoughts (e.g., “I’m never going to make it,” “I’m never going to be happy,” “I might as well kill myself”) and negative emotions and feelings (e.g., feeling lonely, depressed or despair). And these thoughts and feelings may result in a suicide attempt. 

After explaining this cognitive process, Hill worked with the female client in session to draw the CBT triangle and added the client’s thoughts, feelings and behaviors using the client’s cognitive process as a guide.

Once Hill’s client was able to see and understand her own cognitive process, they talked about what coping skills the client could develop to prevent her from making another attempt. For example, she could talk to a trusted friend or loved one or schedule a session with her therapist when she noticed she was engaging in negative self-talk. She could also attend a support group with others who share similar lived experiences or participate in a fun activity with a family member to lift her emotions. 

Hill also used the CBT triangle exercise to help the client develop a detailed safety/crisis plan that included the triggers and warning signs that could lead her to suicidal ideation and the supportive people and actions that could help her avoid causing further harm to herself or others. 

Torzala, who is trained in trauma-informed therapy and eye movement desensitization and reprocessing, often uses journaling and mood tracking to help clients better understand their emotions and recognize that feelings and emotions, especially negative ones, can be temporary. She asks clients to monitor and track their moods over the course of a few weeks and record how they are feeling two or three times a day at any time they choose. In session, Torzala helps clients explore their emotions and feelings to see if they felt a particular way at a certain time of the day and if something was going on in their life that could have triggered the emotional response. 

When clients are suffering from depression or a low mood, they can have a limited mindset that skews their perception of life and may lead them to believe that their negative thoughts and feelings will last forever, Torzala notes. But this exercise, she says, helps clients identify how they are feeling and recognize that a thought or feeling can be temporary. 

For example, after experiencing negative feelings or emotions earlier in the week, a client may say, “Yesterday, I was actually feeling OK and I had the motivation to take a shower and go to the store.” The recognition of a changed emotion, Torzala notes, can help clients realize that thoughts and emotions are fluid and can fluctuate and that their intensity can and will pass. 

The limited mindset that many of these clients have can be deceiving, Torzala continues, and can lead them to feel that suicide is the only option they have at that time to escape whatever pain they are feeling.

“What their mindset is leading them to is something so final,” she says. But clients can learn that what they are experiencing will eventually pass. 

Ginsberg, who has received suicide education and training through the American Foundation for Suicide Prevention, uses a journal exercise to help clients work through unresolved childhood trauma and help them feel empowered.

The unresolved childhood trauma they often carry leads to a lifetime of feeling insecure, irrelevant and not good enough, Ginsberg says. This affects clients’ self-esteem and self-worth, which could escalate into a mental health disorder and/or crisis, and, ultimately, a suicide attempt. 

In the journal exercise, Ginsberg asks clients to visualize a time when they felt unsafe, threatened, unloved, unappreciated or unseen as child. She then asks clients to write that child a letter and tell them something their adult self would like that child to know. The client, for example, could express love for the child or a willingness to protect them. They could also let the child know that now they are safe and whatever was threatening them in the past is no longer relevant, she says. 

“Through journaling, the hope is that the client will understand that the young child did what they needed to do to survive and that they didn’t have the power to stop the abuse,” Ginsberg explains.

Clients can feel empowered when they realize that they are no longer that child and they are no longer a victim, she adds, and as an adult, they now have a choice and can work toward healthy alternatives rather than attempting to take their life to resolve childhood and other life wounds. 

A strengths-based approach 

Sommers-Flanagan advises counselors to use a strengths-based approach to treat clients who have survived a suicide attempt. “We’ve traditionally pathologized suicidality and previous attempts and doing so tends to cultivate shame,” he says. “Instead, strengths-based approaches view suicidality as a normal response to very painful and difficult life situations.”  

Sommers-Flanagan, along with Rita Sommers-Flanagan, co-authored the ACA book Suicide Assessment and Treatment Planning: A Strengths-Based Approach, which outlines a seven-dimension model that allows clinicians to integrate solution-focused and strengths-based strategies into clinical interactions and treatment planning. They elaborate on this model in the Counseling Today article “Taking a strengths-based approach to suicide assessment and treatment” (published in the July 2021 issue). “Our approach doesn’t replace traditional approaches but complements or supplements them,” Sommers-Flanagan notes.

He also stresses that it’s important for clinicians to recognize that it will be challenging for clients to develop and practice strengths-based techniques. “What’s really important is to be alongside clients in their pain and encourage and support them to try these hard things that will, in some cases, feel unnatural for them because it involves them trying to be positive when they’re feeling so negative,” he says.

It’s helpful to let clients know that focusing on a strengths and resources approach takes time, Sommers-Flanagan adds. Letting clients know they will be supported in the process can help them move at their own pace and comfort level. 

The following strengths-based techniques, Sommers-Flanagan says, can be useful for clients before and after a suicide attempt. 

Normalize suicidal ideation and suicidal behavior. Counselors who work to normalize suicidal ideation and behavior can help clients see that suicidal thoughts and behaviors are a normal part of the human experience and that they happen because of acute pain, helplessness and distress. 

“Many, many people have suicidal thoughts, and frequently people who are having suicidal thoughts view suicide as a possible solution to their pain and distress,” Sommers-Flanagan says. “They feel they didn’t have any other options that would make the pain and distress go away.” 

He recommends counselors normalize suicidality so clients don’t feel labeled or judged and are more willing to speak openly and honestly about their lived experience. 

Express gratitude to others. Counselors can invite clients to establish a gratitude practice. They can suggest clients write a note to someone to express their gratitude or give that person a call, Sommers-Flanagan says. And if clients do not want to write or reach out to anyone, then counselors can ask them to sit and reflect on how it might feel to express meaningful gratitude. Gratitude practice is based on positive psychology principles and often works best when practiced once or twice a week, he adds. 

Engage in intentional acts of kindness. Sommers-Flanagan says the suicidal distress clients often feel can be so overwhelming that it is all they can see in their lives. Counselors can help clients refocus their attention by inviting them to engage in small acts of kindness toward others. He suggests counselors discuss these acts with clients in session and have them monitor whether their kind actions resulted in positive thoughts, feelings or experiences. 

Develop a mindfulness meditation practice. Counselors can discuss how mindfulness has been shown to prevent depressive relapses or the worsening of depressive symptoms, and then invite clients to develop their own meditation practice. Again, for clients who have survived a suicide attempt, developing a mindfulness practice may be difficult, Sommers-Flanagan notes, so whenever counselors prompt clients to integrate positive practices into their lives, empathy and encouragement are essential.

Focus on three good things. It is common for these clients — and other people — to ruminate over depressive thoughts at the end of the day and worry about what tomorrow will bring, Sommers-Flanagan says. To address depressive reviews of the day and anticipatory anxiety for tomorrow, clinicians can ask clients to name three good things that happened to them during the day and have them reflect on why those good happened to them before they go to bed. This activity helps clients begin a habit of positive thinking, he says, and they may learn to recognize how they create positive experiences in their life, rather than lamenting about any negativity. 

Supporting family members

The family members of suicide attempt survivors can also struggle in the aftermath of a suicide attempt. The counselors interviewed for this article agree that family members are often in shock and can experience feelings of guilt, shame, embarrassment and anger after their loved one’s suicide attempt.

Hill says the event often leaves families scrambling to understand the reason(s) behind why their loved one tried to take their own life. Family members may also be despondent over the fact that their loved thought of fatally harming themselves, she notes. And they may feel guilty and wonder what went wrong in the family to cause the attempt or why they couldn’t prevent it from happening.

After a suicide attempt, some family members become fearful that their loved one will make another attempt, says Ginsberg, who is a suicide loss survivor, so they may begin to obsessively monitor the person’s behavior. In fact, she says she’s had several family members of clients say, “I can’t leave them alone.” She recalls one client whose family member slept outside their bedroom door each night to listen for any signals of distress.

Sommers-Flanagan says cultural factors can affect how individuals and families respond to a suicide attempt. Some family members will shut down socially and isolate themselves from others because they feel ashamed and embarrassed. And families may respond by keeping the attempt to themselves because grieving outside of the family unit is not culturally acceptable.

The counselors interviewed for this article all agree that family members need support for their own mental health needs and clinicians should work with families to ensure they take advantage of mental health services.

“They [family members] are at a higher risk for having a mental health crisis themselves [because of] the stress that it puts on a family,” Ginsberg says. “They need somewhere safe to talk about their struggles without making [their loved one] feel guilty.” 

Ginsberg uses CBT techniques when working with family members of suicide attempt survivors to help them process their feelings and emotions. In one exercise, she asks family members to imagine the worst thing that could happen in relation to their loved one’s struggles. Ginsberg provides an example of a possible exchange that could occur between a counselor and the family member during this exercise. The counselor can start the conversation by asking: 

What is the worst thing that can happen? 

My loved one will take their life.

What will be the consequences of the worst thing that can happen?

I will be devastated and it will impact the rest of my life.

How have you coped in the past? What can you do to cope better this time?

My loved one has been struggling for a long time now. I have had to deal with fear and anxiety around their possible suicide attempt. It has caused me to be depressed and on edge all the time. I need to practice self-care. If I’m not in a stable mental place, then I will have a difficult time being present for them.

What is more likely to happen?

Because my loved one has a great support system and mental health services, it is likely they will not make another attempt and they will begin to heal.

So is it worth living in a place of fear all the time?

The reality is that I will still feel some fear, but I know that I’m doing everything in my power to help my loved one. I can only control my own actions and emotions and must surrender to those things that are out of my purview.

Ginsberg says the real fear many family members have is that if their loved one died by suicide, they wouldn’t be able to survive it or that they couldn’t live with themselves. So she uses this worst-case scenario exercise to help family members understand that if the worst thing did happen, they could handle it and that it’s no one’s fault. The exercise also helps family members recognize their own strengths in the midst of a crisis and shows them that they can develop the coping skills they need to move forward in life.

The counselors interviewed for this article agree that clinicians can use psychoeducation to educate families about suicidal ideation, mental health disorders, and the triggers and warning signs that can lead someone to a suicide attempt. They can also refer family members to support groups for suicide loss survivors and/or mental health organizations that can provide additional community resources.

The counselors also stress the importance of helping families realize that their loved one is in critical need of support from both the family and mental health professionals. They suggest counselors encourage family members to participate in creating their loved one’s safety/crisis plan and to keep a copy of the plan, along with the counselor and the client. 

Families need to remember that “the true victim” is the person who attempted suicide, Hill says. Suicide attempt survivors “don’t ever think, ‘How can I hurt my family?’ They just want the pain to stop,” she notes. 

And it is the responsibility of the counselor, with help from the family, to focus on the needs of the client, Hill adds.

Torzala, who is a suicide loss survivor, says family members can significantly help a suicide attempt survivor heal through empathy while understanding and validating their emotional struggle. She also states that family members should recognize their own emotions after a suicide attempt because this can be a traumatic experience for them as well. 

The need for proper training

When Strait decided to seek treatment regarding his own suicide attempt, he did not have a good experience with mental health professionals because they were not adequately trained to treat people with suicidal ideation.

 “I had a psychiatrist tell me that I had a good family [and that] everything would be OK, so I shouldn’t be sad,” Strait recalls. And “I had a counselor who told me they didn’t think I needed to talk about it [because] it had been years since my attempt.”

Some counselors, Strait says, are not comfortable talking about suicide because of the stigma that surrounds the topic. (See below for more on the stigma associated with suicide.) He says it is important for counselors not to panic or overreact when a client discusses their suicidal thoughts and negative feelings. 

Torzala has experienced the unfortunate fallout from counselors who were not prepared to treat these clients. “In the past, I’ve had clients who were fearful to disclose their suicidal ideation because of the past actions of former therapists,” she says. “After they disclosed suicidal ideation, the therapist contacted family members or authorities, and sometimes the client was sent to inpatient involuntarily. Suicidal ideation can be common with certain mental health disorders, and it’s important to normalize that with the client in order to openly discuss it. This is where suicide prevention happens.”

Torzala recommends clinicians work through their own fears and misconceptions about suicide so that they can feel comfortable discussing the difficult aspects of suicidal ideation with their clients.

Ginsberg also advises clinicians to seek out training opportunities with mental health organizations and continuing education programs to ensure that they have the skills necessary to help suicide attempt survivors and their families rebuild their lives. And if possible, counseling students can take suicide education courses in graduate school, Strait adds.

In 2016, Strait finally found a counselor who made him feel comfortable to begin treatment. The two worked together to reframe his cognitive distortions using CBT.

“The biggest thing is that he [the counselor] was comfortable talking about [suicide] and made it OK for me to talk about it,” Strait says. “I felt no judgment, no pity. I did feel compassion. He met me where I was at on the journey and helped me move forward.”



Resources on suicide prevention


The stigma of suicide 

Historically, suicide has been linked to tragic mental illness and has been considered to be criminal behavior, notes John Sommers-Flanagan, a professor of counseling at the University of Montana. This negative historical perspective has led to stigma surrounding suicide.

“Suicide has often been categorized as something only ‘weak’ or ‘emotionally vulnerable’ people do,” says Támara Hill, a licensed professional counselor (LPC) and owner of Anchored Child & Family Counseling in Monroeville, Pennsylvania. “I have had some clients call it ‘selfish’ or ‘cowardly,’ when the reality is that the person just wants their pain to stop — or the client is seeking some control over their own life.”

Chris Sandwell, an LPC and director of accreditation, training and certification with the American Association of Suicidology (AAS), says stigma comes from a lack of understanding or fear, which might explain why people don’t know how to support, understand or help a person in a suicidal crisis.

“The counseling profession can help provide a place where people can talk openly and honestly about their suicidal thoughts, provide alternatives to calling the police and threatening hospitalization and provide true collaboration with people who are [considering] suicide,” Sandwell argues.

In 2014, AAS designated a membership category for suicide attempt survivors to “create a seat at the table for suicide attempt survivors and people with lived experience of suicide,” Sandwell explains. Today, she says about 15% of AAS members are people who identify as having a lived experience of suicide, including attempt and loss survivors, and about 34% of AAS members are clinicians.

Rick Strait, an LPC and the substance use division director and suicide prevention coordinator at the Community Counseling Center in Cape Girardeau, Missouri, says he has experienced stigma from colleagues and other mental health professionals because of his own suicide attempt. 

When Strait first sought treatment to process his past suicide attempt, he says a friend, who is also a counselor, told him that he should never tell anyone about his suicide attempt because prospective clients would not want to work with him.

“When I first started sharing my story, I had professionals give feedback that maybe I shouldn’t be in this field or [that] I shouldn’t share my lived experience,” Strait says. “Ironically, almost every time I share my experience with professionals or do a training with professionals, I have a least one professional reach out to me and share their struggles, past or present.”

Strait says some of his colleagues have expressed fears about getting help for their past attempts or suicidal thoughts because of how it may impact their career. And others have shared about family members and how their struggles with suicidal ideation have affected them. 

Tammi Ginsberg, a licensed clinical professional counselor with a private practice in Woodsboro, Maryland, says suicide attempt survivors are stigmatized for the same reason that people with other mental illnesses are also stigmatized. “Quite frankly, it comes from a place of ignorance,” she says. “Making a suicide attempt is a serious symptom of a mental health condition, just like having a heart attack is a symptom of a serious cardiac issue. It’s just not seen the same way.” 

Counselors must take on the challenge of advocating for better mental health treatment and normalizing diseases of the mind, Ginsberg argues, and the counseling profession must insist that prospective counselors who are interested in working with this population get ample training.



Lisa R. Rhodes is a senior writer 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.

Disarming anger

By Bethany Bray September 23, 2022

Anger is personified in the animated Disney-Pixar film Inside Out as a stocky, red-faced character who is prone to mistrust and often takes things personally. He is easily upset and when he perceives a situation as unfair, he begins to yell and emit flames from the top of his head like a blowtorch.

Although the 2015 film was made with a younger audience in mind, many adults can easily relate to this character. The “flames” that erupt when Anger escalates may be figurative rather than literal, but it can feel just as real as depicted on screen.

Anger is one of a multitude of emotions that is a normal part of the human experience. Clients, however, sometimes avoid talking about their anger in counseling because it can be uncomfortable and hide emotions that may feel more vulnerable for them to reveal, says Kelly Smith, a licensed professional counselor (LPC) who has extensive experience working in the field of domestic violence, including helping perpetrators with anger issues. 

Counselors can play a key role in removing the barriers and stigma that keep clients from addressing their anger, Smith stresses. This includes making it clear that anger is a normal occurrence and something to address when dysregulated. If a counselor is qualified and open to helping clients who feel angry all the time, they should emphasize that on their professional website and bio information, she adds.

“People can struggle with feeling out of control. And sometimes that is expressed as anger,” says Smith, an assistant professor in the Department of Counseling at Springfield College in Massachusetts. “It’s important to normalize that this is something to get help for.”

Interrelated emotions

Anger can be such a complicated emotion that clients struggle to describe it or identify its nuances and connections. An essential first step toward helping clients understand their anger is guiding them to explore the full range of what they’re feeling, says Smith, a member of the American Counseling Association.

Several of the counselors interviewed for this article say they use an emotions wheel to guide clients toward understanding their anger more fully, including emotions that are interrelated. Smith says she uses it in every session as a discussion starter.

In addition to shame and embarrassment, anger can be connected to feeling threatened, overwhelmed, vulnerable, resentful, overlooked or unrecognized and a range of other experiences that clients may struggle to express or connect the dots, says Reginald W. Holt, an LPC in Connecticut and Missouri and a licensed clinical professional counselor (LCPC) in Illinois. 

Holt created and led an eight-week mindfulness-based relapse mitigation program that focused on emotion regulation, including anger management, with clients at an outpatient addictions treatment facility. Holt, along with Mark Pope, published the findings from this program in a 2022 article in the Journal of Human Services.

Holt says he noticed a common pattern of emotions among the program participants, all of whom were men on probation and parole. Many of the men would become angry — at their situation, at others or at the universe — when they experienced triggers, lapses or cravings for substances, he recalls. These feelings would often be intensified if the client was feeling unsupported because their family or loved ones had established firm boundaries or ostracized the client, which often happens within support networks when addiction and related behaviors cause problems, notes Holt, an ACA member.

When clients had relapses, their anger was often accompanied by feelings of remorse, powerlessness, frustration, defeat or fear that the rest of their life would be an unsuccessful, frustrating struggle to gain control over substance use, says Holt, a master addiction counselor, advanced alcohol and drug counselor and internationally certified advanced addiction counselor. This pattern would reoccur time after time until clients learned to recognize these interrelated concerns and respond, rather than react, to feelings of anger.

“Anger is the surface level, but if you dig down below that, it’s usually a sense of not having control and below that, a sense of fear,” he says. “It boils down, in some respect, to feeling overwhelmed, feeling helpless [and] feeling like it’s all too much.”

Exploring the origins

When a client appears to be struggling with anger, Smith recommends counselors conduct a thorough assessment for mental health issues that sometimes go hand in hand with anger such as substance use, domestic violence or abuse, posttraumatic stress disorder, borderline personality disorder, depression as well as medical issues such as brain injury or chronic pain. Clients who present with anger may need counseling work to address these other related issues first, either within the counseling sessions or in additional work with a specialist or in a group setting, she notes.

Anger can also be a “learned behavior,” says Toni Moran, an LPC and co-owner of a consulting and counseling practice in Denver. This was the case for Moran, who grew up in a household where there was a lot of yelling — and never an apology or repair. As an adult, it has taken a conscious effort to unlearn these patterns she saw as a child, she says.

Clients who, at an early age, witnessed caretakers, adults or even siblings default to anger and lose control of their emotions learn that it’s a way to connect, communicate, be heard and get one’s needs met. “It takes a lot of self-awareness and insight to say, ‘I probably could have handled that in a better way,’” Moran says, “And a lot of the people who are coming to me with anger problems weren’t modeled that in childhood.”

Moran and the other counselors interviewed for this article agree that delving into a client’s childhood and historical narrative can be a key way — for both client and counselor — to understand the context for their angry feelings and behavior.

However, Moran stresses that practitioners should use their “counselor intuition” to gauge how soon a client might be ready to talk about their childhood and the origins of their anger. Building rapport and trust with clients who struggle with anger should take priority, she says.

Alice Edwards, an LPC who specializes in helping clients with anger at her Houston private practice, agrees that questions about a client’s childhood can help shed light on the roots of their anger, as well as make it clear to the client that long-held patterns of anger and/or aggression will continue to plague them until they are processed.

Edwards begins these discussions by asking a client to remember the first time they experienced the type of anger that they struggle with now as an adult. She prompts them to recall how old they were, what was going on in their life at the time, how they felt and if the situation was ever resolved.

The counselor’s role, she says, is to guide the client with gentle questioning that can help uncover connections between past situations and patterns that occur in their adult life.

This was the case for a male client of Edwards’ who was struggling with problematic, angry feelings toward his work supervisor. Conversations about the client’s upbringing revealed that his father, who was in the military, had been absent a lot during his childhood because of work travel. And whenever the father returned home, he was extremely strict and often angry with the client. Exploring this history in counseling helped the client draw connections between his anger at his father and his anger at his boss and helped him move toward healing, Edwards recalls.

Diffusing anger

Humans express and present anger in different ways, which means each client will have unique needs and they may need to work on a variety of issues in tandem with their anger in counseling. These issues can include processing trauma, improving self-compassion, learning communication skills or conflict management, and working on better expressing their needs. And for some clients, it may be all of the above.

The counselors interviewed for this article, however, agree that clients won’t be able to delve into a treatment plan until they learn coping mechanisms to diffuse their anger in real time. They shared the following techniques to help clients learn to calm themselves, reflect and find ways to reroute their emotions to keep anger from escalating into problematic and negative patterns and behavior.

Breathing and mindfulness. Breathing techniques can serve as a useful and easily accessible way for clients to pause whenever they feel themselves becoming angry. Breathwork was the first layer of the mindfulness method that Holt used with clients in the relapse prevention program. Focusing on breathing often calmed the participants to the point where they could be mindful of their other physical sensations, range of emotions and five senses, which further helped them to slow down. The clarity of mind clients gained through this progressive mindfulness technique allowed them to reflect on the “rational and reasonable choices” they could make to replace anger as a response mechanism, notes Holt, an associate professor in the Department of Counselor Education and Family Therapy at Central Connecticut State University.

Breathing techniques work well as a primary and go-to tool for clients because they can bring the person out of fight-or-flight mode and reactivate their logical, problem-solving ability, Holt explains.

He encourages clients — and students, when teaching mindfulness as a counselor educator — to practice and hone these skills during mundane, everyday activities such as brushing their teeth, washing the dishes or taking a shower. Individuals can learn to focus on the temperature of the water or the taste of the toothpaste instead of letting their mind wander, he explains. And when it inevitably does, they can learn to gently lead themselves back to a mindful focus without self-judgment.

He challenges clients (or students) to gradually increase the amount of time they practice mindfulness, and then they discuss what did and didn’t work and what they learned when they debrief with him in session (or class). 

Safety planning. Creating a safety plan is a common and important practice in domestic violence work, but it can also be helpful for clients who struggle with anger, Smith says. The key is to create safety plans with clients before they need them and to have the client come up with the content. 

Clients can often identify how, where and why their angry behavior usually occurs, Smith notes, which makes them the best experts on ways that behavior can be diffused or curtailed. So the safety plan won’t have the desired effect unless the client, not the counselor, identifies the steps in their plan, she stresses.

For example, a client who has a history of physical expressions of anger might suggest removing the doors from the kitchen cabinets so they cannot be slammed or replacing metal or wooden drink coasters in their living room with cardboard ones so they cannot be thrown as easily, Smith says.

A client can also create a plan to use when they’re with a person or in a situation that usually makes them angry. Perhaps they come up with a signal to let a trusted friend or partner know when they’re starting to feel angry and need to take a break, she says. Then the client could go outside and take a quick walk or use other coping mechanisms to calm themselves.

Safety planning in this way ensures that clients have healthier alternatives at the ready to express themselves or release their anger, Smith adds.

Journaling. Journaling can serve as an outlet to document the strong feelings that clients who struggle with anger sometimes have trouble tolerating or understanding. Moran asks each of her clients to find or purchase a notebook for journaling as they begin counseling work together. Clients can often benefit from documenting their thoughts and tracking their progress in a journal, she says, but it can be a particularly helpful medium for clients who are working on anger issues. Moran sometimes suggests these clients turn to their journal after an angry incident to record the feelings and sensations they experienced and, in turn, reflect on what they learned.

Prompting clients to keep track of the events and interactions that happened before an angry episode, Edwards adds, can help them connect the dots between triggers and patterns that influence and lie underneath their anger.

Writing assignments, however, may not be a good fit for all clients. Edwards says that she sometimes encourages clients to record themselves (using audio or video) on their cellphones, which they can replay later.

Releasing through movement. Anger is an active emotion, so it helps to move one’s body to release it, Moran says. She sometimes teaches clients who struggle with anger a technique she calls “shaking leaf,” where they stand and shake their body to release tension, anger, frustration and related feelings. She says she often stands up and does this with clients to encourage them and illustrate the technique in session. Any movement that feels therapeutic to a client can be helpful in this way, she notes. Moran also finds that tapping and bilateral stimulation techniques can be useful for clients to process anger in the moment. 

Movement in the form of exercise played a key part in helping a client who once sought counseling from Moran after being written up twice at work for angry behavior, including throwing a chair. He had chronic stress that was unaddressed, and it escalated to a boiling point when co-workers were not completing tasks in a certain way, she recalls. He also felt intense shame about his behavior after the fact.

In counseling, Moran and the client found that a three-pronged combination of coping mechanisms —  physical exercise (walking his dog and riding his Peloton bike), journaling, and breathing and mindfulness techniques — provided the outlets he needed to release, process and reflect on the anger he was feeling. The client found it particularly helpful to do breathwork and body scanning in his car when he arrived at work each morning and at the end of his day before driving home, she says.

Moran counseled the client for two years and he was never written up by his employer again. By the end of their sessions together, he continued to journal regularly to process his feelings and thoughts, but the client no longer found work to be a source of frustration, she says.

Interjecting humor. Alison Huang, an LCPC with a private practice in Silver Spring, Maryland, often counsels clients who struggle with anger. When a situation seems unfair, clients who are prone to anger often take it personally, Huang says, so she sometimes takes a creative, humorous approach to help clients who react in this way to reframe the situation.

Huang often suggests that clients picture people who have made them angry as a minion, the yellow creatures who first appeared in the 2010 film Despicable Me. Loyal and loving, the minion’s childlike behavior and attempts to help often result in unintended mayhem.

Picturing the person who cuts you off in traffic, a difficult co-worker or your irritating neighbor as a minion makes it hard to get angry at them because they didn’t mean it and they don’t know any better, Huang explains.

She sometimes plays video clips of the minions for clients in counseling sessions as they talk through scenarios that made them angry. She asks clients: How would you feel and react if you were a bystander in this scene with the minions? How is it different than your reactions in real life?

Introducing the minions as a coping mechanism often makes clients laugh and instantly diffuses their anger, she says.

“Humor and reframing are a good combination for [addressing] anger. Having some laughs shifts their energy suddenly, softens their demeanor and increases their capacity for empathy for others and themselves,” Huang continues. “It’s very easy for those who struggle with anger to take things personally. [In counseling, try and] find ways for them to detach and keep from taking it personally — get out of that loop and find new thought patterns.”

Befriending anger

Anger is often viewed with negative connotations (both by clients and within society), but counselors can guide individuals to see that it is only negative when it’s dysregulated and results in unhealthy behaviors and patterns. When used in a productive way, anger can inform us, alert us and protect us — it can actually be a good thing, Moran says.

In fact, her goal, she says, is not to help clients get rid of anger — which is a normal human emotion and will always be present — but to help them learn to process it in a more constructive way.

Depending on a client’s needs and situation, Huang uses a combination of methods, including relational therapy, mindfulness, and acceptance and commitment therapy, to help individuals process anger and the deeper issues that sometimes underlie it, such as fear of abandonment.

According to Holt, the crux of helping clients overcome dysregulated anger is helping them learn to see it as an emotion to explore and learn from, rather than something to suppress or be overcome by. He aims to help clients rewrite their “automatic pilot” use of anger as a go-to response.

Offering the client psychoeducation on the nervous system and how anger can be connected to humans’ fight-or-flight response is an important first step in this process, Holt says, as well as teaching mindfulness techniques, such as body scanning, to help clients become attuned to how anger feels in their body and the physical cues that indicate it’s beginning to escalate, such as a clenched jaw or upset stomach.

“It can be an empowering experience [for the client] to acknowledge that ‘I felt angry and I sat with it, investigated it and realized that it didn’t have to overtake me,’” Holt notes. 

Drawing from psychologist Tara Brach’s RAIN method, Holt used mindfulness to teach the participants in the relapse prevention program to explore and learn from their anger. Brach’s acronym can be a helpful way to introduce clients to the idea of pausing to consider why they’re becoming angry and finding other ways to channel that energy, Holt notes. RAIN prompts users to:

Recognize what is happening

Allow and acknowledge that the experience is happening

Investigate it with curiosity

Nurture with self-compassion

Holt says the clarity that comes with this measured, calm response also helps clients to learn to take in the full context of an anger-provoking situation and assess whether it is a source of true harm or simply perceived harm.

It can be a hard thing to learn for those who have used anger to express themselves or react to uncomfortable feelings for a long time, Holt admits, and it will need to be repeated and practiced. It also requires them to be able to identify the full range of emotions that they’re feeling and deploy self-compassion.

This focus on exploring anger creates “an opportunity to slow down; become more intimate and familiar with your emotions as they rise, crest and fall; and be able to tolerate the discomfort of that in the moment,” Holt continues. And it introduces skills for “checking where the anger is residing in your body and befriending it, rather than being afraid of it and avoiding the impulse to discharge it immediately because it’s uncomfortable.”

Moran takes a similar approach with clients by using techniques to help them detach and separate themselves from their anger. For example, she says counselors can encourage clients to view situations that provoke anger with curiosity. It can be helpful for clients to consider why their anger is showing up now, she adds, and think through the events that led to these feelings by asking what activities they were doing, who they talked to and what happened earlier.

Slowing down to consider the potential reasons for and the context of their anger in this way can also help them identify needs that aren’t being met, and in turn, prompt them to communicate their needs instead of responding in anger, Moran says.

She also teaches clients who struggle with anger to rephrase their “I” statements. Instead of thinking or saying, “I am angry,” they can learn to describe it with language such as “I feel anger” or “Anger is showing up right now.”

It can be helpful to teach clients to view anger as a person who is coming to visit, Moran notes. “Have the client address it, [saying] ‘I see you and I feel you. What are you trying to tell me?’ It’s often trying to warn us that something’s not right. And when we ignore [its message], it gets to a boiling point.”

Anger’s aftermath

A final — and important — step for clients to overcome problematic anger is learning the skills to acknowledge when they have responded in anger or hurt others and apologize, when appropriate, Moran says.

She uses the repair techniques outlined in the Gottman method of couples therapy with clients — both individuals and couples — who struggle with anger. Depending on a client’s needs and situation, a person can work on repair individually by writing in a journal or recording their thoughts or collaboratively by speaking with others who were affected by their angry behavior.

Repair is helpful because it prompts the client to acknowledge what happened as well as its context, Moran says. “They can come back to the person or people who were involved and say, ‘I was feeling angry and this is why, and it wasn’t OK for me to do or say XYZ,’” she explains.

For clients, the process of making amends by verbalizing or writing how they felt and behaved during an angry episode can also help strengthen their skills of distancing themselves from their anger, separating facts from feelings and communicating their needs, Moran adds.

“When I see shame [in clients who struggle with anger], it’s often because their angry behavior resulted in hurting someone else or made them look bad,” she says. “I try and help clients separate themselves so they don’t see themselves as the emotion.”

Benjavisa Ruangvaree Art/


Clients who don’t see anger as a problem

Practitioners may encounter clients who describe angry feelings and behaviors in counseling sessions but don’t see them as inappropriate or problematic.

In some cases, anger has become such a go-to or automatic response for a client and a way to get their needs met that they don’t even recognize it as anger, says Kelly Smith, a licensed professional counselor (LPC). It can also be a learned and internalized behavior, especially when a person has not had examples in their life of people who deal with anger in a healthy way.

Smith, who has extensive experience working in the field of domestic violence, says this is not uncommon among clients who are perpetrators of abuse. She once worked with a perpetrator of domestic violence who mentioned in session that every time they were upset with their partner, they went into the kitchen and tightened all the lids on the jars so their partner would have trouble opening them.

This client described this behavior as playing “a joke” on their partner, recalls Smith, an assistant professor in the Department of Counseling at Springfield College in Massachusetts. They didn’t see it as an act of aggression or anger; they thought it was funny. 

“When working with perpetrators, they might not see themselves as angry, but it’s a part of their situation,” Smith explains. “They often minimize [anger], deny it or justify it to make it something other than what it is. They might say ‘I only did X …’ to make [behaviors associated with anger] sound smaller than what it was or deny that it was aggression or abuse in the first place.”

For example, one of Smith’s clients shared that in an attempt to leave an argument with their partner, they simply “picked their partner up to move them out of the way.” But the police report shared another perspective: This act of “moving” their partner resulted in a broken door. 

It may go without saying that clients who struggle with anger can benefit from learning coping skills to be able to calm themselves and respond in a less aggressive way. But, as Smith notes, individuals who minimize or ignore their anger may not be ready to learn these skills — let alone address the heavy issues that can dovetail with anger, such as substance use or trauma.

She recommends counselors find and focus on motivation to connect and prompt growth with these clients. For clients who minimize anger, this often takes the form of finding a reason to change besides wanting to avoid getting in trouble for their angry behavior (e.g., wanting to change because they love their spouse), Smith says. And, most importantly, these reasons for motivation to change must be concepts (or people) that the client, not the counselor, identifies, she emphasizes.

Clients may need to revisit these conversations and remind themselves of their motivation throughout counseling work for anger or aggression. Smith suggests that counselors prompt the client to talk about where they want to see themselves in 10 years: How will they behave? What will be different in their life? How will they handle things that have made them angry in the past? Then, have the client identify things they need to do one week, one month and one year from now to reach that 10-year goal, Smith says.



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.

Voice of Experience: Diversity and third-culture kids

By Gregory K. Moffatt September 21, 2022

Pita Design/

My client was a 19-year-old female presenting with anxiety. She had just started college, and her anxieties had led to trouble concentrating and making friends, and they sometimes kept her awake at night. She was also troubled by the fact that until recently, she had been easygoing and didn’t get ruffled quickly.

The client was a child of a missionary family, and for over a decade, she had lived in South America. But she was born in the United States and had spent nearly all her grade school years in a rural community on the east coast where she now attended college. She and her family also made regular visits back to the United States during those ten years when she was living abroad.

One would have thought that returning to the United States for college after spending the last 10 years in South America would have been an easy transition for her. After all, she was already an easygoing individual, she functioned well in her adoptive culture, and she never had any issues on her sabbaticals home to the United States. But it wasn’t easy, and she couldn’t understand why.

But I had an idea.

When she left the United States, she was only nine years old. The world she knew was long gone because of the passage of time and her own development from child to adult. On top of that, in her visits back to the United States, she spent most of her time looking up old friends or enjoying the company of relatives until her trip was up and she had to go “home” in South America.

As a white girl with blond hair, she was an anomaly in Ecuador. She lived in a community where English wasn’t spoken. Although she spoke Spanish without much of an accent, it was still not her first language. She was not a true Ecuadorian.

But when she returned to the United States, she also discovered that she was not a true American either. Being gone most of her adolescence, she had missed 10 years of acculturation. TV shows, movies, music and cultural events were just some of the things she couldn’t relate to. It was like she walked into a very long movie just at the end; she didn’t know what was going on around her.

My client was what is referred to as a third-culture kid — people whose identity is influenced by their parents’ culture and the culture(s) in which they are raised. Third-culture kids are often the children of missionaries, nongovernmental organization workers or military families. My client obviously didn’t totally belong to the guest culture (Ecuador), but she didn’t belong to her home culture anymore either. Not every third-culture kid’s experience, of course, is as stressful as my client’s. Most of her stress stemmed from the fact that she was not prepared for feeling like an outsider in her home culture.

Transitions from one culture to the next are easiest when the cultures are similar, when the visit is short, and — as is often true for Americans — when they take U.S. culture with them. When I hear about someone from the United States traveling abroad and I learn that they stayed in American hotels, ate American food and spoke nothing but English, then I know they took America with them.

But for missionaries and NGO families, living on the economy almost necessitates diversity of culture, longer stays, and an inability or lack of desire to take America with them. The “American” stands out and may take years to be thought of as an insider.

At the same time, attempting to gain acceptance in the chosen culture by default also means leaving one’s home culture behind. Third-culture individuals are like ships without a flag.

In our never-ending attempts to improve our understanding of diversity, it would be easy to overlook third-culture kids. Based simply on appearance, people may not realize someone is a third-culture kid. I could have easily missed the significance of my client’s third-culture status and focused only on her anxiety. That would have, at best, slowed down her healing.

Recognizing that she was really neither American nor Ecuadorian helped her understand why she didn’t seem to fit in a culture where she looked like everyone else. This realization was the beginning of her developing coping strategies that worked quickly and helped her symptoms of anxiety abate.

Large international agencies often employ mental health workers to assist their personnel when they transition to a new culture as well as when they are ready to transition back to the United States. But smaller agencies such as the one my client was associated with may leave navigating this transition up to the individual, which is what happened to my client.

When I was a graduate student in the 1980s, “diversity” generally focused on issues of race. Fortunately, our thoughts on diversity have evolved since the 1980s, but we still have a long way to go. And we can start by recognizing overlooked areas of diversity, such as third-culture kids, and developing strategies to help them.



Read more on the nuances of counseling third-culture kids in a recent article from Counseling Today: “Growing up between cultures



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.