Monthly Archives: November 2022

Looking back, moving forward: COVID-19 and Indian Country

By Nicola A. Meade, Roni K. White and Carol ZA McGinnis November 10, 2022

Throughout American history, the United States government, despite well-documented treaties, has unjustly treated Native Americans. Treaties ratified in 1851 and 1868 were violated during the COVID-19 pandemic national emergency, which may be surprising to people who believe that the failure to uphold such legal documents is an outdated issue. 

As noted by the Substance Abuse and Mental Health Services Administration (SAMHSA), there are eight domains of wellness — physical, relational, occupational, mental/emotional, intellectual, spiritual, environmental and financial — and any domain can affect another. This article will highlight how COVID-19 disproportionately impacted several domains of wellness for Native people and how counselors can address increased mental health concerns. 

The physical toll 

In a December 2021 article published in The Princeton Review, Riis Williams reported about a study conducted by Princeton University researchers, which found that U.S. COVID-19 mortality rates of Native Americans were 2.8 times higher than white people. Comparatively, this study also found that mortality rates were 1.6 higher for Black Americans and 1.8 higher for Latinos than white people. Comorbid factors contributing to these significantly higher rates include lack of access to affordable health care, poverty, historical and current treatment by the U.S. government, and higher rates of high-risk health issues. 

Shortly after the pandemic began, Kolby KickingWoman highlighted a distressing problem in a June 2020 article published in Indian Country Today, writing that “tribal leaders are working to keep their citizens safe from the coronavirus while juggling attacks on tribal sovereignty.” For example, in April 2020, the Cheyenne River Sioux and Oglala Sioux tribes implemented highway checkpoints for the purpose of contact tracing to reduce the spread of COVID-19. According to a May 2020 article in Indian Country Today, Cheyenne River Sioux Chairman Harold Frazier said that vigilance was required because the health care system on his reservation had “only eight hospital beds and six ventilators,” which was alarming given the high rate of infection that was occurring in the United States at the time. Nevertheless, South Dakota Gov. Kristi Noem tried to stop these efforts by giving the Native nations a 48-hour timeline to remove the checkpoints. The Cheyenne River Sioux Chairman Frazier and Oglala Sioux Tribe President Julian Bear Runner ignored the order, stating that they would remove the checkpoints when they deemed that it was safe to do so. Gov. Noem then involved the Bureau of Indian Affairs and threatened legal action. In May 2020, an increased number of positive COVID-19 cases led the Rosebud Sioux Tribe to also implement checkpoints on tribal land highways. 

In an action of solidarity, a bipartisan group of state lawmakers wrote a letter in support of these tribal actions to Gov. Noem, and they cited the 1851 and 1868 Fort Laramie Treaties, which clarify that the state “has no jurisdiction over the highways running through Indian lands in the state without tribal consent.” Gov. Noem responded by sending a written plea to then President Donald Trump for federal intervention. Citing this plea, U.S. Sens. John Thune and Mike Rounds and U.S. Rep. Dusty Johnson sent a letter to U.S. Interior Secretary David Bernhardt requesting clarification on jurisdiction. The Association for Multicultural Counseling and Development’s Native American Concerns (NAC) group also wrote a position letter in support of tribal sovereignty. In the end, Native sovereignty was maintained, and the decision to have contract tracing checkpoints was applauded. 

This conflict, however, did not end with the unjust challenge over highway checkpoints. As predicted by Chairman Frazier, when members of the Cheyenne River Sioux Tribe and Oglala Sioux Tribe fell ill with COVID-19, they did not have sufficient medical resources to meet the needs of their communities. And despite having available hospital beds in South Dakota, tribal members were forced to seek medical assistance in other states, traveling as far as Denver and Cheyenne, Wyoming. This not-so-subtle form of discrimination led to an Eight Circuit ruling that supported the 1868 Great Sioux Nation Treaty, which requires the United States to provide “competent physician led-health care.” 

A similar discriminatory health care policy occurred at the Lovelace Women’s Hospital in Albuquerque, New Mexico, where pregnant Native American women were singled out for COVID-19 testing based on their race and zip code. In a June 2020 article in ProPublica, Bryant Furlow unveiled that this hospital’s secretive policy resulted in some Pueblo Nation mothers being separated from their newborn babies for up to three days. No other hospital in the area enacted a similar policy for new mothers, and the practice was finally identified and stopped months later. This egregious practice is evocative of the 1860 U.S. cultural genocide policy to separate Native children from their parents and place them in government boarding schools, which ceased in the 1970s. Policies of this nature are reminiscent of historical traumas, and they also create new traumatic experiences and contribute to negative mental health outcomes. 

The financial toll 

The pandemic also severely hurt Native Americans economically when public commerce restrictions led to a significant economic downturn. Many of the revenue streams Native nations rely on are in the hospitality and service sectors, gaming industry and public-driven enterprises, such as the Hualapai Tribe’s Skywalk over the Grand Canyon. Generally, these enterprises were either closed or experienced significant revenue losses during the pandemic, which decreased the economic health of the community-based tribes. 

Although many Americans experienced financial hardship due to the ramifications of the pandemic, the Native American circumstances were compounded due to the intersection of the high percentage of COVID-19 deaths with tribal economic interdependence for survival. According to the 2020 report by the National Center for American Indian Enterprise Development, more than two-thirds of Native-owned businesses suffered significant revenue losses. 

As noted in a 2020 report by the Federal Reserve Bank of Minneapolis, Native American employment had the biggest drop in April 2020 of any racial group. This decrease in employment was also highlighted by Robert Maxim, Randall Akee and Gabriel Sanchez in a 2022 Brookings article that exposes the vast differences in unemployment rates across Native American, Asian American, Black and white populations. In January 2020, the unemployment rate for Native Americans was 7.5%, Black Americans was 6%, Asian Americans was 3%, and white Americans was 3%. In March 2020 the unemployment rate drastically increased, with 28.6% unemployment for Native Americans, 16% for Black Americans, 14% for both Asian Americans and whites Americans. The unemployment rate in January 2022 displayed improvements, with 11.1% unemployment for Native Americans, 8% for Black Americans, and 4% for both Asian Americans and white Americans. The authors of this article acknowledged a prolonged disparity, noting it was the “first time the government published monthly unemployment data on Native Americans.” This former exclusion has had negative effects on economic recovery efforts, supports and research, which was highlighted in a 2022 Journal of Counseling & Development article by NAC members.  In addition, as noted in a 2021 report by the Food Research and Action Center, the pandemic also exasperated food insecurities in a unique way for Native communities, resulting in locations running out of basic supplies at unprecedented rates.

On a positive note, Mark Trahant, in a May 2022 article published in Indian Country Today, noted that members of Congress intended to use a recent U.S. Congress report that detailed persistent structural barriers that have limited economic opportunities within Native communities to inform public policy. The American Rescue Plan’s investment of $31 billion into Indian Country is an attempt to bridge these gaps. The U.S. Congress report highlighted the interconnectedness of economic status and resources in relation to health outcomes. Much is still unknown, including the investment’s impact, yet the hope is that these positive movements can make a tangible difference.

The mental health toll

The loss of multiple family members and tribal elders who were the carriers of traditional knowledge and language can be especially difficult to bear, given the depth and breadth of such cultural information on personal and tribal identity. This can be especially devastating when the elder was the last living person with knowledge that predated the U.S. policy of boarding schools, which systematically removed Native American youth from their families and was an intentional form of cultural genocide.  

These losses were experienced by Native Americans in various geographical areas, including rural, suburban and urban areas, and on reservations. Native clients living in urban areas away from their Native communities, which have suffered great losses, might have faced barriers and restrictions that prevented them from participating in grieving rituals, thus complicating their grief. These clients may have also experienced isolation and disconnection from ceremonies, cultural practices and community support due to limitations caused by the pandemic, adding further emotional challenges. 

Local, state and federal policies that have racial disparities can add exponentially to bio-psycho-socio-spiritual aspects of the presenting problem with severe implications that reach beyond the non-Native pandemic experience. Due to these distressing impacts, practitioners should be aware of the historical trauma that the pandemic has triggered for Native American people who have suffered multigenerationally from U.S. betrayal and a failure to support Native interests. In a November 2021 NPR article, Adrienne Maddux, executive director at Denver Indian Health and Family Services, and Spero Manson, director of the University of Colorado’s Center for American Indian and Alaskan Native Health, shared that the pandemic had heightened

Ruslana Iurchenko/

historical trauma and the “sense of pain, suffering of helplessness and hopelessness” for Natives who have endured oppressive circumstances for generations. These observations dovetail with Allyson Kelley and colleagues’ findings in a 2022 article published in the American Indian and Alaska Native Mental Health Research that confirm significantly higher rates of American Indian and Alaska Native (AI/AN) children experiencing orphanhood as a result of the pandemic. 

The shelter-in-place orders and other mandates contributed to disturbances in physical and mental health due to the disruption in social, cultural, and economic practices and norms that are at the core of what it means to identify as a Native American. These circumstances contributed to increased rates of depression, suicidality and other pandemic-related stressors. A post-pandemic poll conducted by NPR, the Robert Wood Foundation and Harvard T.H. Chan School of Public Health found that Native Americans now suffer from increased depression, anxiety, sleep problems, stress and posttraumatic stress disorder. 

Before the pandemic, 50% to 88% of homes on tribal lands lacked internet, broadband and even phone services, so it is easy to see how these disparities elevated difficulties for Native Americans to transition to shelter-in-place orders, virtual opportunities and telemedicine. In a 2022 article published in American Indian and Alaska Native Mental Health Research, Amanda Hunter and colleagues reported that some Native American researchers used funding and advocacy to improve technological infrastructure, yet this help was limited to a few areas. These honorable efforts, however, were not able to mitigate the long-term effects of the technological disparities. 

A 2022 article in Shift Nursing reported that the depression rates for people in North Dakota had risen from 19.2% in 2020 to 33.3% in fall 2021. And of particular concern, the 2019 Fargo Cass Public Health Assessment found “a suicide rate of 45.1 for Native Americans in North Dakota, compared to the national average of 13.4.” This article also highlights access to insurance and costs as barriers to mental health treatment. 

On the positive note, mental health practitioners benefit from knowing that protective cultural factors can serve as a resource for Native American clients. Amanda Hunter and colleagues detailed how the protective factors of community, relationality, abundance, strength and resilience found in AI/AN communities have improved outcomes during the pandemic. These protective factors may exist for Native American clients who are struggling with post-pandemic issues and help them to pave a way forward through their struggles with anxiety, stress and depression. Many Native communities executed resilience during the hardships, disparities, challenges to sovereignty and disruptions to protective factors. Continued mental health support is essential to sustain resilience. 

Clinical considerations

Mental health practitioners demonstrate ethical care by incorporating how the aforementioned tolls affect Native clients while also seeking knowledge and understanding to maintain cultural competency. Counselors can learn more about current events within Native American communities by reading Native news resources such as Indian Country Today, IndianZ and Native News Online. Along similar lines, it is culturally responsible to understand that each tribe has its own culture and to be aware of tribal resources. Here are a few tribal resources that might be helpful depending on location: Northwest Portland Area Indian Health Board, Native Hope, Indigenous Story Studio, One Sky Center, We R Native, Center for Native American Youth at the Aspen Institute, First Nations Development Institute, and Centers for American Indian and Alaska Native Health. More general resources can also be found at the Indian Health Service (an agency under the U.S. Department of Health and Human Services) and SAMHSA’s Tribal Training and Technical Assistance Center websites.

In September, Kristi Taylor-Bond, a nationally certified addictions counselor and a chemical dependency clinical supervisor in Alaska who works with Alaskan Native populations, shared the following description of how the pandemic has affected the Alaska Native community with the NAC group: “COVID has halted in-person gatherings, which are essential to Native communities. It is common for Alaska Native crafters and artists to gather at the Native hospital and other corporation-run locations to sell crafts [and] traditional foods and to visit with friends. With these activities ceasing, many elders have been more isolated and unable to earn income from selling their art. Elders are especially vulnerable to mental health decline when they are not able to connect with loved ones.” This statement reverberates how important it is for counselors to access clients’ understanding of culture and their sense of belonging to culture as well as how disruption from this culture affects mental wellness. 

AI/AN clients benefit when counselors include the following spectrum factors for cultural consideration during sessions:

Connection/disconnection: Explore how AI/AN clients are experiencing connection to their community and cultural practices.

Contributor/burden: Ask AI/AN clients how they perceive their community is experiencing their needs. Does the client see their needs as a burden to others? Is there balance to how the client views their own contribution and needs? 

Collective/isolation: Determine AI/AN clients’ degree of connection to elders. This is important because elders hold wisdom for healing and challenging times.

Balance/imbalance: Guide AI/AN clients to reflect on what is working and explore the balance of wellness from the client’s cultural perspective. 

Cultural responsible therapeutic services also include the method in which counseling is offered. Telehealth is becoming a more widely used modality, so additional considerations are important to keep in mind. Taylor-Bond also shared the following with the NAC group: “While telephonic and video sessions may be a very successful alternative for urban and younger folks, Alaska Native elders and those living in more rural settings are not finding the same success, in my opinion. There is a really beautiful part of building rapport with AN elders that I have found, and that is just being with them. … Lots of the rural kids and adults I’ve worked with first get to know you by experiencing you.”  

SAMHSA and the U.S. Department of Health and Human Services have shared research informing how cultural disruption is a risk factor for suicide and mental illness in AI/AN communities. 

What counselors can do

Policy informs funding and laws, and funding delivers resources to initiate change. Counselors can engage in local and federal advocacy to improve facilities, research, treatment and access. There are many ways counselors can advocate and encourage changes. Understanding how local laws affect mental and behavioral health allows clinicians to discuss the impact and needs of Native American clients and practitioners with legislators. It is essential for counselors to know the systemic barriers that create limitations for Native American clients to obtain mental health care in order to inform elected officials on ways to improve access to these services. Identifying methods to deliver culturally appropriate services will improve the quality of service and access to care. 

When counselors advocate for efficacious culturally appropriate services, policy makers can pass legislation that protects vulnerable communities, builds access to culturally competent services and designates funding to increase equitable services and research. Supporting scholarship through funding is necessary to increase culturally appropriate interventions for therapeutic services. Currently, the funding for AI/AN research is 0.01% of the mental health research budget of the National Institutes of Health. In their article, Hunter and colleagues revealed how the pandemic has disproportionately affected Native communities, and more research is needed to explore the underlying factors and impacts of COVID-19. 

In their 2022 article, Kelley and colleagues shared how communities across Indian Country established policies, adapted services, created education and service delivery strategies, and developed resources to keep individuals and families safe. Many of these communities partnered with federal agencies, including the Centers for Disease Control and Prevention, Federal Emergency Management Agency, and Indian Health Service. 

Advocacy and progress take time and can provide healing to Native American communities. It was not until the passing of the American Indian Religious Freedom Act of 1978 that Native Americans could more freely worship in the United States. In 2021, Deb Haaland became the first Native American to serve in the presidential cabinet as the U.S. Secretary of the Interior. In August, Mary Peltola became the first Alaskan Native elected to the U.S. House of Representatives. In July, more than 1,000 acres of land were returned to the Onondaga Nation in New York, acknowledging them as the original stewards of the land. This recognition allows for healing and restoration as it further emphasizes sovereignty.  There remain numerous injurious land policies fueling advocacy efforts, including the Dakota Access Pipeline and national monuments such as Bears Ears and Grand Staircase-Escalante.

The American Counseling Association began its 2022 Conference & Expo with a land acknowledgment. This acknowledgment is essential in the collective healing process and promotes an understanding of the compounding historical and current trauma many Native people endure in their lived experiences. This understanding provides counselors with a window into how the complex traumas may present in symptomatology and offers insight to healing pathways. It truly takes all of us to create a representative government and institute change to heal and progress together.



AMCD Native American Concerns group

The Native American Concerns group is one of seven focus group for the Association for Multicultural Counseling and Development (AMCD), a division of the American Counseling Association that works to promote ethnic and racial empathy and understanding. AMCD encourages changing attitudes and enhancing understanding of cultural diversity. The Native American Concerns group actively supports Native voices in research and provides advocacy for Native counseling issues. It is a resource and community base for Native counselors and those who serve Native populations. Learn more by visiting



Nicola A. Meade is a national certified counselor, a licensed clinical professional counselor in Maryland, a licensed professional counselor in New Jersey, the co-vice president for the AMCD Native American Concerns group, and an assistant professor of counseling and psychology at Georgian Court University. Her extensive work includes serving as a domestic violence advocate for Native women, increasing counselors’ understanding and awareness of Native voices, and researching counselor identity and workplace-based racism. Contact her at 

Roni K. White is a national certified counselor, a licensed clinical professional counselor in Maryland and a co-vice president of the AMCD Native American Concerns group. She founded Apricity Wellness Counseling, a small private practice in Gaithersburg, Maryland, focusing on trauma, spirituality, minoritized women and relationships. Visit her at 

Carol ZA McGinnis is a certified spiritually integrated psychotherapist, a board-certified telemental health practitioner, a national certified counselor, a licensed clinical professional counselor in Maryland and a current member of the AMCD Native American Concerns group. She is an associate professor of counseling in the graduate counseling department at Messiah University. Her research interests include functional anger, spirituality in counseling, and Xbox video gaming. To learn more, visit


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


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

A beginner’s guide to alexithymia

By Jerrod Brown November 8, 2022

Alexithymia is a complex, subclinical phenomenon characterized by cognitive-affective functioning impairments that can affect as many as 10% of the general population. Typically, individuals with alexithymia struggle to recognize, identify and describe their feelings. This often includes trouble discerning between emotions and physiological sensations. Because alexithymia is a known risk factor for a wide range of psychological and physical health problems, this psychological construct has significant implications for professionals working in the field of mental health. In fact, the failure to accurately identify the presence of alexithymia can significantly impact the intake, screening, goal-planning and therapeutic processes. Therefore, mental health professionals should become familiar with the wide array of disorders, traits and experiences often associated with elevated rates of alexithymia. 

Unfortunately, many mental health professionals lack the necessary training and expertise to accurately identify and effectively treat the unique and complex symptoms of alexithymia. A strong contributor to this predicament is the lack of training and educational programs that offer workshops and coursework dedicated to this important and complex topic. The goal of this article is to provide mental health professionals with a basic introduction to alexithymia by highlighting information in four essential areas: (a) symptoms and red-flag indicators, (b) diagnostic comorbidity, (c) screening and assessment and (d) intervention and treatment considerations.

Symptoms and red-flag indicators

Symptoms of alexithymia can vary from person to person and are often influenced by many neurological, biological and psychosocial factors.

The cognitive factors associated with alexithymia can include: 

  • Deficits in the regulation of thoughts, emotions and bodily processes 
  • Difficulty with introspection
  • Inhibition and impulsivity issues
  • Limited imagination and fantasy life
  • Constricted patterns of thought
  • Reliance on concrete thinking almost to the exclusion of symbolic thinking
  • The affective factors associated with alexithymia can include:
  • Blunted or limited personal experience of emotions
  • Difficulty identifying and describing emotions
  • Emotion dysregulation
  • Failure to identify the causes of personal feelings
  • Inability to seek and use support systems to help with emotional problems
  • Limited use and understanding of verbal and nonverbal emotional cues
  • Poor emotional awareness
  • Emotional avoidance and suppression 
  • Difficulty distinguishing between emotions (e.g., telling the difference between anxiety and anger)
  • Weak affective theory of mind
  • The social factors associated with alexithymia can include:
  • Interpersonal communication characterized by coldness, flatness and a lack of emotion
  • Lack of empathy
  • Loneliness
  • Nonassertiveness
  • Perspective-taking deficits
  • Social conformity
  • Verbal and nonverbal communication deficits
  • Weak social attachments
  • The physiology factors associated with alexithymia can include:
  • Physical sensitivity to the experience of different sensations
  • Tendency to mistake affective responses as physiological experiences or dysfunctions

Diagnostic comorbidity

Alexithymia often co-occurs with a diverse array of psychiatric, trauma-based, neurocognitive, neurodevelopmental and substance use disorders, so it is likely that mental health professionals provide services to clients impacted by alexithymia on a regular basis. In particular, individuals with alexithymia are quite prone, but not limited, to presenting with another disorder that features affective symptoms. It is important to note that alexithymia can be viewed as a risk factor for psychopathology as well as other conditions. The following highlights some mental health conditions often associated with alexithymia.

Substance use and other addictive disorders. The prevalence rates of alexithymia are higher among individuals with substance use and addictive problems than the general population. In addition, individuals with alexithymia appear to be at risk for more severe alcohol-related problems than those without alexithymia. This has led some researchers to posit that alexithymia could place a person at risk for alcohol use problems. Failure to consider the role of alexithymia in alcohol use could undermine the effectiveness of any interventions.

Stress-related disorders. Research has consistently linked alexithymia to physiological stress markers as well as stress-related disorders. For instance, individuals with alexithymia often exhibit elevated levels of chronic stress on measures of cortisol awakening response and cortisol secretion during the dexamethasone suppression test. Other evidence includes increases in inflammation and atypical immune responses, which could be consequences of prolonged exposure to stress.

Posttraumatic stress disorder. Posttraumatic stress disorder (PTSD) is a condition characterized by heightened reactions, anxiety, intrusive memories and nightmares, and other-related symptoms. The onset of PTSD is precipitated by exposure to a traumatic event (e.g., violence, accidents, natural disasters). Some of the same traumatic experiences that lead to PTSD could also contribute to the development of alexithymia. As a result, mental health professionals are encouraged to screen for alexithymia in clients presenting with PTSD.

Insecure attachment. Research has found higher rates of alexithymia among people with insecure attachment patterns compared to people with secure attachment patterns. Insecure attachment patterns may also cause the impacted individual to experience trust issues, fears of abandonment, general discomfort and decreased coping abilities. And both insecure attachment patterns and alexithymia have been linked to increases in emotional and behavioral problems. Therefore, attachment-based therapists are encouraged to become informed about alexithymia. 

Traumatic brain injury. Traumatic brain injury is temporary or permanent brain damage caused by a blow or some other wound to the head. Common symptoms of traumatic brain injuries include impulsivity, aggression, emotion dysregulation and poor coping skills when under duress. Research shows that many people who suffer from a traumatic brain injury also experience alexithymia.

Neurodevelopmental disorders. Alexithymia has also been found to be elevated among people diagnosed with  neurodevelopmental disorders, including attention-deficit/hyperactivity disorder, autism spectrum disorder, fetal alcohol spectrum disorder, and intellectual and developmental disability. Routine screening for alexithymia among people diagnosed with a neurodevelopmental disorder may lead to improved treatment outcomes.

Hypothalamic-pituitary-adrenal axis dysfunction. The hypothalamic-pituitary-adrenal (HPA) axis may play a role in alexithymia. This system is responsible for regulating stress responses and ensuring the body adjusts to evolving environmental conditions. Exposure to stressful situations can elicit chronic hyperactivity of the HPA axis. In such instances, a person becomes at risk for stress-related physical and mental health problems. Because of the potential connection, I recommend counselors also become informed about the HPA axis when learning about alexithymia. 

Somatic symptoms. Individuals with alexithymia tend to score higher on measures of physical distress than the general population. These physiological differences could help explain the higher prevalence of anxiety and depression symptoms among those with alexithymia. During times of distress, people with alexithymia may experience and complain more about psychosomatic-based symptoms.

Dissociative tendencies. Dissociation occurs when there is a disconnection among a person’s cognitions, emotions and actions. The presence of dissociation could play a role in the emergence of alexithymia or vice versa. This is particularly salient in people who have experienced trauma such as neglect and abuse. In such cases, the development of dissociation and alexithymia could serve as an adaptive response that prevents a person from being overwhelmed.

Sleep disturbances. Individuals with alexithymia often report comorbid sleep problems. These can include difficulties with staying awake or falling and staying asleep. Emotional problems that are similar to alexithymia have also been observed among individuals experiencing sleep deprivation. 

Language problems. Individuals with alexithymia often struggle with verbally expressing their own emotions. In addition, individuals with alexithymia have trouble comprehending the verbal communications of other people. Therefore, problems with language processing could be an important causal influence on the development of alexithymia.

Executive dysfunction. Individuals with alexithymia commonly exhibit deficits in executive function, which is a set of cognitive, affective and behavioral skills that enable a person to plan and perform specific tasks. In particular, cognitive flexibility, inhibition and working memory are often described as the primary aspects of executive function. It is important to note, however, that many other constructs fall under the umbrella of executive function. The symptoms of alexithymia and deficits in executive function may be exacerbated by various forms of extreme stress and trauma. When this occurs, it can significantly impede goal achievement and adaptive functioning.

Immune function dysregulation. A growing number of studies have reported an association between alexithymia and immune system dysregulation. The same stressors that cause alexithymia could also alter how the immune system functions. A grave consequence of immune system dysregulation includes proneness to a diverse array of psychosomatic illnesses. Encouraging the client with alexithymia to maintain regular contact with their health care provider is warranted.

Emotional regulation deficits. Individuals with alexithymia often present with emotional dysregulation issues. For example, individuals with alexithymia usually struggle to express or understand their feelings and the feelings of others. As a result, many mistake the symptoms of alexithymia as a lack of empathy. Consequences of emotional dysregulation include difficulties with establishing and maintaining relationships across the life span. In some instances, this could lead to a breakdown in the therapeutic alliance. 

Worry and rumination. Individuals with alexithymia typically experience high levels of worry and rumination. Worry is generally distinguished by fears of danger, whereas rumination is characterized by thoughts about loss and failure. These repetitive cognitive processes are common in internalizing disorders (e.g., anxiety, depression).

Deliberate self-harm. Empirically based research has found an association between alexithymia and a history of substance abuse and deliberate self-harm. Such self-injurious behaviors could be an attempt to cope with emotional dysregulation, which is frequently exacerbated by alexithymia.

Suicide risk. Alexithymia could serve as a risk factor for suicidal behaviors. Individuals with alexithymia are prone to depression, anxiety and other affective problems, all of which are also predictors for suicidal behaviors.

Screening and assessment

Clinicians should carefully screen for alexithymia prior to the development of mental health and substance use treatment plans. The Toronto Alexithymia Scale (TAS-20) is one instrument counselors can use to screen for alexithymia. The TAS-20, which is commonly used in neuroscience studies, is a 20-item, self-report questionnaire that measures skills in the areas of emotion recognition, emotion description and perspective-taking. Several empirically based articles have been published pertaining to the efficacy of the TAS-20.

When screening, clinicians should watch for increased symptom reporting. Individuals with alexithymia are prone to confusing emotions and feelings for physiological problems with their bodies. In turn, this group is disproportionately likely to overreport and seek medical care for physiological problems. This is another example of maladaptive coping in the context of alexithymia. 

Ground Picture/

As mentioned in the previous section, individuals with elevated stress and anxiety, burnout, or a history of trauma are predisposed to alexithymia. Therefore, systematic screening and assessment for alexithymia is encouraged in these groups. Trauma-informed counselors would also benefit from learning about alexithymia. 

Emotional numbing and emotional suppression are two other areas that mental health providers should consider during the intake and treatment planning process. Emotional numbing is the affective process of minimizing or eliminating the experience of feelings. Like alexithymia, this could be viewed as a temporary coping strategy that is deployed to protect against the consequences of trauma. And emotional suppression is a common way that individuals with alexithymia regulate their feelings. This may be traced back to difficulties in recognizing and understanding emotions that characterize alexithymia.

It is also critical that mental health professionals obtain information from collateral informants when screening for alexithymia. In many instances, the client may lack insight into their own symptoms, which renders self-reported information as insufficient. So conferring with family members, friends and co-workers can help illuminate the nature of the client’s symptoms and their impact on global functioning. In addition, consulting with any other professionals that work with the client can be informative.

Intervention and treatment considerations

Individuals with alexithymia typically have worse mental health treatment outcomes than those without alexithymia. In an effort to address this quandary, research has focused on identifying interventions that help improve outcomes for individuals with alexithymia. This section highlights potential considerations that mental health professionals should make when treating alexithymia.

The symptoms of alexithymia likely undermine the development of therapeutic alliances with mental health professionals. Specifically, difficulties with recognizing and describing affective experiences as well as perspective-taking make it difficult to develop interpersonal closeness with others. 

In addition to limiting the development of the therapeutic alliance, alexithymia could be associated with poor treatment engagement. In combination, these suboptimal outcomes in the therapeutic process contribute to an increased likelihood of negative short- and long-term treatment outcomes in individuals with alexithymia.

The difficulties that alexithymia presents in terms of the therapeutic alliance and treatment engagement are particularly salient in substance use treatment settings. Clients with alexithymia may be dependent on the use of substances to cope with the affective symptoms of their condition. The failure to account for and address alexithymia during the therapeutic process decreases the likelihood of good treatment prognosis.

Individuals with alexithymia are also prone to poor treatment attendance and adherence, which can be expected among clients with poor treatment engagement. Thus, failure to complete treatment programs and relapses are common in clients with alexithymia.

The research literature on the treatment of alexithymia has grown in recent decades, and there is now a substantive list of interventions worth considering when treating clients with alexithymia (see table below). Psychoeducation offers one promising treatment option for clients with alexithymia. A limited but growing body of research indicates that supportive and psychoeducational approaches to therapy may be effective in treating alexithymia. Interpretive approaches to therapy, however, appear to be less effective with this population.

Alexithymia intervention table by Jerrod Brown

Mindfulness training may also be a critical component to incorporate in the treatment of alexithymia. For instance, mindfulness-based training has been linked to increased emotional effectiveness. So using mindfulness-based approaches may result in improved emotional awareness among clients experiencing alexithymia. 

Music therapy also holds promise as an intervention for clients with alexithymia. This therapeutic approach is particularly well suited for clients who struggle to describe thoughts and feelings with words. Thus, clients with alexithymia may find it easier to express their emotions in music therapy.

Individuals with alexithymia generally struggle with emotional clarity, which is the ability to recognize and understand the causes of one’s emotions. Development of emotional clarity could help a client with alexithymia not only benefit from treatment but also protect against victimization in their personal life.

Clinicians can also help clients with stress management. A common risk factor for alexithymia is the experience of extreme stress. It is unsurprising, then, that individuals with alexithymia often struggle with stress management. Thus, the development of stress management skills remains a critical target in any intervention for clients with alexithymia.


Alexithymia is a complex and important topic all mental health clinicians need to know. Since elevated rates of alexithymia are found in a host of trauma-based, substance use, neuropsychiatric, neurocognitive and neurodevelopmental disorders, it is likely that mental health professionals will encounter clients impacted by this subclinical, cognitive-affective deficit on a regular basis. Unfortunately, in my experience, few professionals working in the field of mental health have received sufficient education and training pertaining to the topic of alexithymia. 

I strongly encourage all helping professionals to become informed about alexithymia. Here are three ways counselors can begin this process:

  • Seek professional consultation from recognized alexithymia experts.
  • Review key journals in the field on a regular basis to stay abreast of the latest peer-reviewed research on alexithymia.
  • Continue to seek education and training on the best ways to screen for alexithymia and the best intervention techniques to use with clients who struggle to identify and describe their emotions.



Important facts about alexithymia 

Here are some important reminders mental health professionals need to consider when learning about the topic of alexithymia: 

  • Alexithymia is a threat to emotional, social, and physical health and well-being.
  • Alexithymia is not considered a mental health disorder and is mentioned only once in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. 
  • Alexithymia is a trait found elevated among people diagnosed with neuropsychiatric, neurocognitive, neurodevelopmental, trauma and stressor, and substance use disorders.
  • Numerous empirically based articles have been published on the topic of alexithymia. 
  • Alexithymia can amplify stress and its impact on emotional, social, behavioral and physical health.
  • Clients with alexithymia have difficulty understanding, processing, recognizing and describing emotions.
  • During times of increased stress, worry and conflict, people impacted by alexithymia frequently experience an increase in psychosomatic-based symptoms.
  • Alexithymia can impede the therapeutic alliance, especially when mental health providers lack an awareness and understanding of this topic.
  • When becoming trauma informed, it is also important to become alexithymia informed. 
  • Professionals are strongly encouraged to seek out additional training and consult with experts to better understand the implications of alexithymia within mental health and substance use treatment settings.
  • Academic-based institutions and continuing education training programs are encouraged to offer curriculum and workshops pertaining to the mental health implications of alexithymia.



Jerrod Brown is an associate professor, program director and lead developer for the master’s degree in human services with an emphasis in forensic behavioral health and in trauma, resilience and self-care strategies for Concordia University in St. Paul, Minnesota. He has also been employed with Pathways Counseling Center in St. Paul for the past 19 years. Contact him at


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


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

Embracing fandom in counseling

By Samantha Cooper November 7, 2022

Fan communities, or fandoms, are often misunderstood by the public. Fandoms refers to people who share a common interest in an aspect of popular culture. Whether they are huge fans of the Marvel Cinematic Universe or enjoy dressing as anthropomorphic animal characters, also known as “furries,” people who dedicate their free time to a specific piece of media are often seen as “odd” or childish to others.

For example, according to a 2017 article published in Psychology Today, some people consider furries’ desire to dress as animals as a form of sexual gratification, rather than a form of self-expression. In the case of fans of fictional franchises, such as the British science-fiction TV series Doctor Who, the negativity seems to come from a long-established idea that these fans are social misfits and outcasts and that they place more importance on their fictional world rather than reality.

Being a fan of a certain sport or sports team, however, is seen as more socially acceptable and often isn’t considered to be a “fandom” in the same way pop culture fiction is. But even as science fiction, fantasy and superhero franchises become more mainstream in pop culture, those who are deeply enmeshed in fandom culture may still feel as though their passions won’t be properly understood by mental health professionals because of these stigmas.

“Speaking as a science fiction geek myself — I even have a Star Trek tattoo — this subject is really close to my heart. Empathy is important when supporting any therapy client, but because there can be some stigma around fandom communities, empathy is important when supporting fandom clients. If the therapist is coming from a perspective that perpetuates stigma, such as looking down on furry cosplay artists or fanfiction authors, it’s important for the therapist to do the inner work, to grow as a person, to learn how to see the joy in others’ joy,” says Lindsay Meagher, a licensed mental health counselor at Protea Wellness in Seattle. “It’s important to internally approach fandom clients from an open-hearted, open-minded, empathic perspective.”

Using fandom to build rapport

Some counselors embrace “geek therapy,” which integrates aspects of so-called “nerd culture” such as video games, comic books and science fiction media to build rapport with clients.

Geek therapy operates on the principle of affinity, which is using common interests or background to establish a repertoire with a client. If a counselor mentions they share an interest in a particular piece of media or a love of going to fan conventions, the client can feel more comfortable expressing this part of their identity.

Ashley Myhre, a licensed marriage and family therapist at POW! Psychotherapy in Minneapolis, says it’s important for clinicians who are working with this population to create spaces where the clients can feel safe to express themselves.

Myhre has created her practice around the idea of fandom therapy. The logo for her private practice resembles a sound-effect bubble from comic books: It’s a light blue bubble with the word “pow” written in orange, capital letters. She says this design choice helps communicate that her practice is one where clients can bring their whole self to sessions.

“If that’s the kind of client you want to cater to, you need to make your space welcoming,” she explains. Her office space is decorated with rainbow flags, pop culture figurines and stuffed animals, which are images that signal to her clients that her practice is a safe space for people in LGBTQ+ and fandom communities. Her website also contains a statement saying, “Mental health for nerds, geeks, misfits and others outside of the mainstream.”

Counselors who aren’t a part of fan communities can still show their support in small ways, Myhre notes. For instance, she says that little things such as office decorations can make or break a client’s trust. “Do you have any kind of fan art in your spaces? Is your mug from your favorite TV show? What are [some] visual cues you can be sending to clients that it’s a safe space?” she asks.

Counselors can also find ways to learn about fandom and use this knowledge to build rapport with clients. It’s much easier to make your space welcoming to those in fandoms when you understand the basics, Myhre says. And part of that can be done simply by listening to and respecting clients’ passions.

Myhre advises counselors to listen for cues where the client is talking super passionately about some aspect of fandom such as a particular character or object. When she hears this, she will ask the client questions such as “How has this mirrored some of your own experiences?” “How have you come to better understand yourself through being a fan of this media?” “What are the strengths you see in these characters that you want to bring into your own life?” or “How does this align with your values?”

Doc Davis, a licensed professional counselor and owner of Side Quest Therapy in Austin, Texas, takes this a step further by incorporating games, such as video games or online chess, into counseling sessions. This is the approach he takes with one of his clients; he always begins their virtual counseling session by playing a video game together.

“We start our sessions literally online together playing a game,” Davis explains. “We’re not talking about therapy just yet; we’re just playing a game, … having fun, and then the therapy starts to slip in.” When the conversation starts to be less about the game and starts becoming more about the client’s life, Davis puts the game on pause, and they continue the conversation and move into the therapeutic part of the session.

Kashawn Hernandez/

Finding a sense of community

Fandom can also provide a sense of community. Those who struggle to connect with others in real-life communities may find their companions online or in person through a shared love of a piece of media. For people who struggle to make friends, outwardly expressing their fandom makes for an easy icebreaker. Two people wearing the same shirt, for example, can strike up a conversation and form a friendship based on their mutual interest.

Meagher says that while anybody can potentially be drawn to fandom cultures, people on the autism spectrum are often drawn to fandoms. “A lot of fandoms and a lot of passions are autistic special interests,” says Meagher, who is autistic. “Many of us in the autistic community lean into our passions in really beautiful ways that are part of the community’s norms, but that can be jarring for a lot of people outside of the autistic community who maybe don’t engage with the world in that way.”

People in fandom often use social media platforms to connect with each other. Both Facebook and Reddit allow people to join different groups devoted to fandoms, and there are several hashtags that make it easy to find people who share similar fandom interests.

“I know that social media has helped people who are isolated, often as a result of physical disabilities like fibromyalgia, or as a result of being in grad school. … Often people in fandoms are seeking friendship with people that they have something in common with, and it can be a little hard sometimes to make local friends quickly who share in one’s passions, so this makes online social spaces, such as Archive of Our Own, Discord, Instagram, Tumblr, and even Facebook and Twitter, really lifesaving for a lot of us,” Meagher says.

Therefore, it’s important for counselors to recognize the role that fandoms play in people’s lives, and the different aspect and nuances that come along with it, including the prevalence of parasocial relationships, which are one-sided relationships that someone forms with a media persona. (For more on parasocial relationships, see the sidebar below.)

People involved in fandom often consider themselves to be their own community — one with a shared interest. So having a therapist who is also familiar with the concept and importance of fandoms will make a client more comfortable in the therapeutic environment.

“I think if you’re in fandom, you get it. We have this shared experience. … It just makes things so much easier,” Myhre says.

Just knowing that fandoms are valid communities and becoming curious about a client’s passion is a good start and helps counselors connect with this population. Counselors can also consider where their own “geeky” interests lie and make those interests known to their clients, Myhre adds.

Davis agrees that counselors should be open to exploring aspects of fandom that interest them. The name of his private practice, Side Quest Therapy, is a reference that is instantly recognizable to people who play video or tabletop games. It shows that he’s more than a therapist who just happens to play games, he says. It shows that he integrates it into his clinical work.

Counselors, of course, can’t be a fan of everything, so they will encounter clients with different interests. When Myhre has a client who has an interest she isn’t familiar with — such as a particular anime — she’ll watch a few episodes so she can learn a little bit about it and be able to connect better with the client. For example, she may ask, “What are you getting from anime? Is this particular story connecting with you? Are you bringing some of the lessons into your own life?”

Myhre, Davis and Meagher agree that the most important thing is for counselors to be themselves.

If counselors do not specialize in geek therapy or do not find that it fits well with their clinical approach, then they should refer clients to someone who does have knowledge working with this population, Davis says. If a counselor’s first reaction to somebody whose main hobby is cosplay is “What is that?” then it might not be a good match. But counselors who aren’t into fandom, Davis adds, can still put in the work and educate themselves on what fandom means to their clients.

However, in general, a client whose identity is centered on fandoms often works better with a counselor who also has a passion for them. “Can you imagine what it would be like to go to your therapist and [have] them express to you from that same place because they have that same love, same passion and you can recognize them?” Davis says. “If you don’t have knowledge of fandoms, you could seriously consider creating a referral list for people like me who will look at that and be like, ‘Cool, let’s make that happen.’”




Parasocial relationships

Parasocial relationships (i.e., a one-sided relationship between a viewer and a media figure) and fandoms are closely intertwined. Not every person involved in a fandom has a parasocial relationship, but the relationships with fictional characters or actors is often an important part of many people’s fandoms.

As with any kind of relationship, a parasocial relationship can become toxic, but they can also be beneficial. People who are isolated in their real life may find community and friendship online with their peers and with fictional characters, says Lindsay Meagher, a licensed mental health counselor at Protea Wellness in Seattle. Having parasocial relationships can be a way to make real friendships with people online and/or in person by bonding over a shared love of fandoms, they explain.

These parasocial relationships can be a way of exploring aspects of one’s identity, such as gender or sexuality, that they may not be able to do with the people in their lives. Parasocial relationships provide a sense of community and healing that the person may not otherwise have, Meagher notes.

Ashley Myhre, a licensed marriage and family therapist in Minneapolis, says that parasocial relationships can often be handled in a lot of the same ways as real-life relationships. There isn’t a different technique needed to coach somebody struggling with a parasocial relationship.

Myhre sometimes incorporates the parasocial relationships in session. She may ask a client to imagine what the person or character they are in a parasocial relationship with would say to encourage them when they’re in a depressive state, or she may ask the client to find a positive attribute they share with this person/character. If a client’s favorite character is physically fit, for example, then that client may be more inspired to make healthier lifestyle changes because they want to emulate the character or because seeing this character’s lifestyle motivated them to make changes they were already wanting to make in their lives. In addition, seeing a fictional character go to counseling or talk about their mental health can help destigmatize the idea for potential clients.

But at the end of the day, parasocial relationships with fictional entities often come down to people seeing similarities in experiences that are like their own. Someone who is neurodivergent, for example, may not feel accepted in their real-life social circles, so having a parasocial relationship with a fictional character or celebrity who is also neurodivergent can help them figure out their own identity and accept their differences.

“I think so much of it [parasocial relationships] comes down to a feeling of being seen, a feeling of being understood, validation [and] representation,” Myhre says.



Related reading, from Counseling Today:



Samantha Cooper is a staff 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.

Are counselors ready for the metaverse?

By Staci Hayes November 4, 2022

I am  going to be completely honest with you. I have never had Facebook or any social media for that matter. I’m aware that may hurt my credibility, but I never really got into any of it. I wanted to avoid having that conversation with students and clients about why we couldn’t or shouldn’t be friends online. I just never got on board. 

But when I saw that Facebook was changing its name to Meta, the Macy’s Thanksgiving Day parade was selling non-fungible tokens (i.e., a digital asset that links ownership to unique physical or digital items such as art or music), cryptocurrency was on Saturday Night Live, and my husband walked into our house with pricey Oculus goggles, I started to pay attention. Some influential, smart and wealthy people started to express a really big buy-in for this metaverse thing, and I was seeing more and more evidence for its relevance. But I still wondered: What is it and why should I care?

Embracing technology

Before the pandemic, I was a relatively staunch and rigid believer that counseling could not really occur in virtual spaces and counselor education could not be as effective online as it could be in person. It is never really a comfortable place to operate from when you must readily admit that what held you back were your own personal biases about technology, ones that you later learned are inaccurate. From a completely anecdotal perspective, many clients and students have both benefited and grown from relationships that have been created and maintained over Zoom. 

Born completely out of necessity, this shift to online counseling, supervision and education in response to the COVID-19 crisis has been met with a healthy dose of suspicion and apprehension. Appropriately so. With so many of us continuing to use virtual platforms with clients, work from home and teach completely online, it’s the perfect time for counselors and other mental health professionals to discuss the potential benefits and dangers of virtual counseling. 

Will we be able to help, empower and counsel clients virtually anywhere as the world around us becomes more and more technological? Will we be ready for what the winds of change bring our way? And how well will we be able to adapt and calibrate without losing a sense of who we are and what we are personally driven and ethically bound to do? In short, how can we be counselors in this rapidly changing world?

The metaverse of today and tomorrow 

As I began to explore and dabble more with technology-centric disciplines — ones I never thought I would find myself in — I unearthed a growing curiosity in myself about technology. So, like the character Neo from the 1999 science fiction film The Matrix, I decided to take the red pill — the one that offers a glimpse into a world with an uncertain future — and head down the rabbit hole. Please believe that my innate pragmatism, low stress tolerance for cutting-edge technology and counselor professional identity have all acted as a carabiner, hooking me to the safe rock of reason and practicality. 

Along this journey, I discovered the metaverse, which is the next iteration of the internet and is referred to as Web 3.0. This term is often conflated or confused with virtual reality (VR). Although VR provides an opportunity to best experience the metaverse, these terms are not synonymous. The metaverse is the swimming pool, and VR is the floaties (yes, I have multiple children) or life vest that you choose to wear or not. The vest (VR) can undoubtedly improve the quality of your experience but is not necessary for you to enjoy the pool (metaverse) or for the pool to exist. VR may be something that many could avoid entirely, but the metaverse will be harder to ignore because it will impact how we live our everyday lives and represents all the technological advances that will undoubtedly permeate our day to day. For example, it is hard for anyone to even apply for a job without accessing the internet; smartphones are easy to find; and most of us use two-factor authentication and are often asked to use CAPTCHA to prove that we are not robots.

Most people know of the metaverse through movies and television shows such as Wreck-It Ralph, Westworld, Ready Player One and Black Mirror. These shows often depict the metaverse as a dystopian reality, with robots taking over the world, a dispersion of wealth that has devastated some and elevated others to extravagant riches, and everything else in between. And although these Hollywood imaginings are a while — potentially years — away from becoming a reality, people do use VR goggles to maximize their enjoyment of the digital world from a 3D perspective through avatars. 

There is not one specific metaverse yet, but many large companies are currently working to create one. You do not need a search engine or “middleman” to log on to the metaverse, and it can be assessed from a computer, smartphone or smartwatch. Voice recognition, hands-free operation and artificial intelligence are hallmarks of the metaverse. So anyone who has ever told Siri or Alexa to play their favorite song or received a social media ad for products after talking about that product near their listening device can attest to many aspects of the metaverse that are already available.

The potential benefits 

As technology races to catch up to the vision and imagined concept of the metaverse that represents the collision of a physical world and augmented reality, we are given a precious opportunity as counselors to gain our bearings and come up with a frame of reference. What can the confluence of VR and the metaverse do for our clients, our supervision and our education? For me, it is less about a personal love of technology and more about recognizing the changing landscape that is altering how we are collectively interacting.

Regardless of whether counselors choose to engage in this modality or they choose not to pursue it, we as helpers need to be prepared and equipped to handle any of the issues or concerns that will undoubtedly emerge because of its existence. Having difficult conversations and exploring what psychopathologies could potentially be exacerbated by this cultural shift could give us an opportunity to instill a preventive and strengths-based approach. If we as a helping profession had known how access to and popularity of social media would impact our society and how the prevalence of cyberbullying would ravage schools, could we have prevented some of the carnage instead of reacting to it? 

VR opens up creative possibilities in technology and counseling, and there is some research to support that it can be helpful to a wide array of clients. In particular, VR has shown effectiveness in the following clinical areas: 

  • Fear of heights and flying
  • Posttraumatic stress disorder
  • Eating disorders 
  • Substance use disorders 
  • Trauma 
  • Grief and loss

In addition, counselors can use VR to do the following:

  • Engage in role play for social skills interventions with clients 
  • Help clients improve empathy and increase understanding of complex societal issues 
  • Reduce unfamiliarity and mitigate discomfort of mental health treatment  
  • Create spaces for people with disabilities 

A few words of hope and caution

As we enter this technological space and begin to have these conversations, I want to offer an opportunity for reflection.

What we have been doing is not good enough long term. It is important that as licensed professionals, supervisors and counselor educators, we are aware that many of the practices and policies that have been used during the COVID-19 crisis are not rigid and evidence based enough to be enacted for long-term care. As the internet expands and we realize that there is no computer system or program that is not at least somewhat susceptible to penetration, we must be continually focused on preserving client information and confidentiality. We have learned so much from our telehealth experiences that may be applied to our journey with VR and into the metaverse. It is our responsibility to cultivate and encourage ourselves, colleagues, counselors-in-training and newly licensed professionals to not get too comfortable in the current state of operation and embrace the ambiguity that comes from striving for better. It is time to establish best practices that are informed by the protocols and suggestions from the Health Insurance Portability and Accountability Act, the Health Information Technology for Economics and Clinical Heath Act, and Section H (Distance Counseling, Technology, and Social Media) of the 2014 ACA Code of Ethics. 

We must not be willing to compromise the safety of our clients or their information because we are excited about or see the applicability of these technological advances. Issues surrounding confidentiality, affordability, accessibility, equity, emergency situations and credentialing all need to be addressed. And because no legal precedent regarding telebehavioral health has been set yet, we must continue to execute due diligence. This includes detailed and appropriate documentation about clinical services and clear rationale for decision-making. 

Some of the top concerns for counseling in the metaverse include:  

  • Confidentiality and storage of client information: Can we protect clients’ personal information? Can we ensure that what is said in these virtual spaces will remain protected and be heard and shared only with the intended parties? 
  • Affordability and accessibility: Can we ensure that all who would benefit from services and resources in the metaverse will be able to use it, especially marginalized and oppressed populations? (See Daniel Pimentel and colleagues’ article “Virtually real, but not quite there: Social and economic barriers to meeting virtual reality’s true potential for mental health,” published in Frontiers in Virtual Reality in 2021, for a more in-depth explanation of potential barriers.)
  • Client and counselor identification: Can we always verify the identity and location of people within the metaverse?
  • Emergency situations: If a client shares suicidal or homicidal ideations while in the metaverse, will we be able to intervene effectively, keep the client safe and notify the proper authorities? 
  • Evaluation for appropriateness: Can we effectively screen, evaluate and identify those who would most benefit from incorporating the metaverse into counseling and those who might potentially be harmed?
  • Competency: Can we properly train and educate counselors who want to use the metaverse for counseling? (For more on this topic, see Rodney Goodyear and Tony Rousmaniere’s 2019 article, “Introduction: Computer and internet-based technologies for psychotherapy, supervision, and supervision-of-supervision,” published in the Journal of Clinical Psychology.)
  • Unforeseen consequences: Can we provide preventive care for those whose existing emotional and mental health disorders may be exacerbated by the use and installation of the metaverse? 

Preventive care equates to a pluralistic acceptance of technology. Do all counselors need to “goggle up” and dive headfirst into the metaverse? There is no simple, straightforward answer to this question. Deciding whether we should or shouldn’t embrace the metaverse really comes down to our unique interests, skills, passion and ultimately our scope of competency. Self-awareness should guide each of us to choose whether this is something we would enjoy and, most importantly, effectively execute. Adequate and appropriate clinical training in contemporary topics is difficult to find, so we must create specialized training, continuing education, and thorough research on technology and mental health, as well as develop a decision-making model for determining how to appropriately use technology with clients.

We could use a humanistic/anti-reductionist lens to guide our ability to optimize human growth and development with our clients by offering more education, support and meaning attribution. Viewing our clients and counseling students as holistic, purpose-driven and capable human beings could provide context for our students and clients and help them make sense of this technological world and their desired role in it. Only by leaning into technology can we better understand the connection between the metaverse and mental health and predict if an extended and universal misuse of the metaverse could result in mental health issues such as lower stress tolerance, poor emotional regulations, anxiety disorders, porn addiction, phone addiction, narcissism and psychosis. And then we can work to develop appropriate responses before it becomes a cultural crisis.

We must meet this change with a healthy skepticism. It is my hope that as professional helpers and caring human beings, we keep an open but very guarded heart as we consider new technologies. Change is hard no matter who you are, and we need to be kind and patient with ourselves as much as we are with others. As we hear more and more about avatars, non-fungible tokens, blockchain technology, the Internet of Things (i.e., devices and other physical objects that are connected to the internet) and more other-worldly seeming terms, we must stand fast to our counselor identity and not resent the overtechnological existence we find ourselves in. An overall aversion to and resentment of cellphones being glued to people’s hands, and now wrists, are not the best ways to advocate for our clients, especially those who Marc Prensky in 2001 dubbed “digital natives” — people who were born or grew up during the age of digital technology and therefore do not know a world without the internet and technology. Instead, we need to be practical, passionate and curious. 

Accepting this new technological world does not mean that we cannot fight like hell to make it better. We need to have a pluralistic acceptance of technology, accepting the positives that can come from it without losing sight of the inherent dangers. We must be able to disagree, bring alternative viewpoints and find creative solutions to complex problems. As much as the metaverse represents a convergence of a multitude of disciplines, our articulated response needs to represent the art and science of what we do as counselors.

Here are some tips on how to best dip your toes in the metaverse: 

  • Have fun. Try VR yourself and explore the current metaverse.
  • Be practical, passionate and curious.
  • Consider multidisciplinary approaches by incorporating and growing the work you are already doing with a technological spin (e.g., using VR goggles with clients for role-plays or mediations). Counseling has always been a creative process, as Samuel Gladding’s book The Creative Arts in Counseling illustrates.
  • Educate yourself on current trends. Although some clients may not want to get into the “pool” of the metaverse, we must be ready to see any potential danger and protect our clients who are already swimming in it.
  • Have difficult conversations about what this means for us as counselors.
  • Advocate for marginalized populations and make technology accessible for all.

Final thoughts

How well we can embrace cultural shifts while upholding the values and core professional beliefs outlined by the ACA Code of Ethics to benefit clients and continue to grow as professionals will dictate our longevity and significance in the coming decade. As counselors, we adamantly believe and live our personal and professional lives to promote growth and continued development in both ourselves and our clients. So how can we not embrace, with a reflective and introspective heart, all cultural and technological shifts? We do not have to view technology as the enemy of meaningful and sustainable relationships if we are able to collectively work together to instill preventive care. We can take a strengths-based approach that is focused on constantly improving accessibility to our services and removing obstacles for all. 

We have an opportunity to consider how these technological changes will affect both mental health professionals and clients and calibrate how we as a profession are going to respond. Given the chance to rebuild spaces in which people are going to interact, let us advocate for them to focus on diversity, equity and inclusion. Creating a culture that fosters engagement, collaboration and belonging is important because we value individual perspectives and understand that people do not experience the world the same way. We have a chance to help people approach this virtual world with kindness and acceptance and learn to create meaningful and productive lives within it. The metaverse is coming whether we are ready or not, so let’s start the conversation.

Athitat Shinagowin/


Staci Hayes is a licensed professional clinical counselor and was in higher education for five years. She has recently started a nonprofit organization focused on mental health and wellness in the metaverse with a focus on diversity, equity and inclusion. Contact her at 


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


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

Incorporating clients’ faith in counseling

By Lisa R. Rhodes November 2, 2022

A South Asian Muslim woman in her 20s lives at home with her Muslim family and has been struggling in her relationship with her parents. She feels they interfere with her ability to make decisions for herself and treat her like a child.

The woman decides to go to therapy. After listening to the client talk about the issue, the counselor says, “If you move out, this will no longer be an issue.” But this advice was not helpful, and this woman sought out a different clinician, which led her to Nadia A. Aziz, a licensed professional counselor (LPC) at the Empowerment Therapy Center in Manassas, Virginia.

“The client felt the counselor wasn’t informed on how to deal with issues in a culturally informed manner,” Aziz recalls. “The counselor failed the client by not incorporating [her] values” into treatment.

In South Asian cultures, which embrace the spiritual teachings of Islam, Hinduism, Sikhism and Buddhism, it is expected that adults live at home with their families until they either get married or move away for work or college, explains Aziz, who is South Asian and Muslim.

“A counselor suggesting moving out of a family’s home would be insensitive to the [client’s] cultural and religious needs because the client was not able to move out and it wasn’t a realistic expectation,” she says. 

 Aziz, a member of the American Counseling Association, worked with the young woman in therapy to set healthy boundaries and develop assertive communication skills so she could express her feelings and needs to her parents in a way that was respectful of her family’s cultural and religious beliefs.

An evolving practice

This scenario is an example of what many clinicians fear — not knowing how to respond to the religious and spiritual needs of a client. J. Scott Young, a licensed clinical mental health counselor and professor in the Department of Counseling and Educational Development at the University of North Carolina at Greensboro, says his research on religion and spirituality in counseling, which includes conducting counselor surveys, shows that many mental health professionals feel anxious and uncertain about incorporating a client’s faith into therapy.

“They don’t want to do anything unethical,” Young explains. “They’re worried that they don’t know what to do to help people with [these] issues.”

The uneasiness counselors feel stems from a long history of prohibiting the intersection of religion and spirituality in the therapeutic process. In the third edition of Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice (published by ACA), Young and Craig S. Cashwell point out that “religion has long been a highly controversial topic in the mental health disciplines.” They also note that Sigmund Freud and B.F. Skinner, two pioneers of psychology, considered religious and spiritual belief systems to be frivolous.

However, the counselors interviewed for this article all agree the counseling profession, and the mental health field in general, has evolved over the years to regard religion and spirituality as important additions to counseling education and practice. And they stress that with the proper education, training, and focused introspection into their own religious and spiritual beliefs, counselors can effectively bring a client’s faith into the therapeutic process, if that is the client’s desire for treatment. 

In 2009, the Association for Spiritual, Ethical and Religious Values in Counseling (ASERVIC), a division of ACA, developed the Competencies for Addressing Spiritual and Religious Issues in Counseling to serve as a guideline for counselors seeking to incorporate a client’s religion and spirituality into practice. The competencies work in tandem with the ACA Code of Ethics.

Jesse Fox, an ACA member and the current president of ASERVIC, says evidence-based research into the importance and efficacy of religion and spirituality have made them topics for therapeutic exploration. 

“The evidence base for interrelationships between spirituality, religion and mental health has grown exponentially,” says Fox, an associate professor of counselor education at Stetson University. “In the most recent systematic review in 2012 produced by Harold Koenig at Duke University Medical School, there were over 3,000 published peer-reviewed studies documenting the connection between spirituality, religion and health. In fact, the number of studies grows exponentially every year.”

This empirical work has mapped out how these domains — religion, spirituality and health — of human experience function psychologically, he explains. 

“The net effect is that mainstream mental health models have recognized that spirituality needs to be considered alongside of other dimensions of wellness like emotional health or physical health, as well as intersectional models of identity like race and sexuality,” Fox says.

Religion and spirituality continue to be important to many in the United States. According to a 2022 Gallup Poll, 81% of U.S. adults believe in God. Statistics such as this, Fox says, suggest that religion or spiritual matters will likely be “an aspect of a client’s identity” in counseling.

Young, an ACA member, says research has shown that people who have a faith or religious commitment that supports them tend to experience less anxiety and depression, more stability in their primary relationship, and more stability and commitment in their work and career. This commitment “seems to be sort of a buffer against some of the stressors that they might otherwise face,” he explains. “And if that’s that case, [it] sort of helps to support their mental health as well.”

People often use spirituality or religion to make meaning of their lives, notes Young, who treats clients at Triad Counseling and Clinical Services PLLC, which has offices in High Point and Greensboro, North Carolina. “In counseling, we talk to people about their childhood, their parents, their family drama … [and] their sex life — all these are very personal things for people,” he says. “At times counselors are hesitant to discuss spirituality or religion for fear that it is too personal or that they may misstep.” 

Know thyself, know the client 

The counselors interviewed for this article say that before attempting to bring a client’s faith into therapy, counselors should thoroughly explore their own religious and spiritual beliefs, or the lack thereof.

“If counselors have not taken the time, or realized the importance of taking the time, to know themselves — their values, their beliefs, their own spirituality and religious preferences — then that’s not going to be a good match for clients who have needs in that area,” says Amy Evans, a licensed professional clinical counselor in Minnesota. 

“The challenge is making sure we do not push our own values, worldview and perspectives on our client,” Evans stresses, which is something both the ACA Code of Ethics and ASERVIC competencies make clear counselors should not do. “To make sure we’re not doing that, we have to know ourselves,” she adds. 

Aziz says she was able to explore her religious and spiritual identity in undergraduate and graduate school, where she took courses in multicultural counseling and faith-based counseling, as well as other classes that encouraged self-discovery, self-awareness, and exploring one’s own values and biases in the realm of religion and spirituality.

Justin K. Hughes, a LPC in Dallas who offers religious/spiritual integration, most commonly for Christians, says he learned important tools for bringing a client’s faith into treatment from his own experience receiving counseling as an undergraduate student and from the counselors he worked with during his Christian seminary training and clinical internship. 

Hughes, owner of Dallas Counseling PLLC, says these mental health professionals set the model for him by being respectful and humble and always asking questions to assess his needs and learn more about his religious and spiritual experiences. He says he now mirrors these traits in his own practice. 

Faith and self-disclosure

While it is important for counselors to feel comfortable with their own faith and belief systems, the counselors interviewed for this article agree that it is not necessary for clinicians to share this part of their lives with clients. If clients do inquire about their faith, they advise clinicians to be thoughtful in how they respond. 

Young, a past president of ASERVIC, says he doesn’t discuss his spiritual views in session unless the client brings up the topic, and even then, he is careful not to divulge too many details. 

“I have, on occasion, had a client who really wanted to know how I see these things, so I always preference [my response] with ‘We’re here for you,’” Young explains, noting that he will then try to explore what salience religion and spirituality holds for the client and what the client may be trying to learn by asking about his beliefs. 


 “I do not try to deflect or redirect if they are truly curious,” Young says, “but I do want to understand why it is important for them to know my beliefs.”

Aziz says her faith is evident in the photograph she posts on Psychology Today’s directory of mental health providers and her practice’s website. “I wear the head scarf, the hijab, [so] it’s kind of hard to miss,” she says. “A lot of times I do get contacted through those avenues, so I am implicitly disclosing that I am Muslim, and they are looking for a Muslim therapist.”

If clients inquire to know the specifics about her faith, Aziz says she always brings the discussion back to what the client is looking for and what they need in treatment. Although a discussion of Aziz’s faith may sometimes be helpful in building rapport with a client, she is mindful that it is not relevant to the therapeutic process. 

“A lot of times it is [about] setting boundaries with them,” she says, “and making sure they understand that the counseling session is not about me, it’s about [them], keeping the focus on them.”

Hughes, who specializes in treating obsessive-compulsive disorder (OCD), anxiety and related disorders, is a member of the International OCD Foundation, which has been examining the role of religion and spirituality in the treatment of OCD during the past couple of years. 

Hughes says he is “usually fairly open about being a Christian” with clients if they bring it up. For example, some of his clients have asked, “Are you a Christian?” “Would you be willing to pray with me?” and “I’m not very religious. Are you OK with that?” He only provides specific information if he feels it will be a therapeutic benefit for the client, which he notes varies case by case.

Counselors do not have to share the same religious or spiritual beliefs as their clients to be effective in therapy, yet for some clients, having a match in faith may matter to the client. Evans, an associate professor and program director of the master’s in counseling program at Bethel University in St. Paul, Minnesota, says research shows that what matters in practice is the quality of the therapeutic relationship and the counselor’s responsiveness to the client. 

“If a counselor is trained well and really considers the client’s worldview, culture and values — then that can be helpful to the [therapeutic] relationship,” says Evans, an ACA member. A counselor’s training and ability to modify therapeutic techniques to meet the client’s needs is what is most helpful in practice, she stresses, not the counselor’s faith.

Young acknowledges that a counselor’s faith may be important for some clients. If there’s not a match in faith, it may be barrier for some clients who may not feel as safe in the relationship as they should, he explains. But “as long as the counselor is open and meeting the client where they are [and] they’re not anti-religious or struggle with it themselves,” Young says, “it really shouldn’t make much of a difference.”

Broaching the topic

Counselors must first determine a client’s therapeutic needs to find out if they would like to include their faith in counseling. The counselors interviewed for this article suggest bringing up the topic of religion and spirituality in the first session and including it on intake forms. 

“One of the most important things is to … broach the topic,” Evans says. “If we don’t let clients know it’s OK to talk about it [religion and spirituality], they may not know it is acceptable to bring it up.”

Evans says counselors should also inquire about a client’s faith on the intake form. Then during the first session, they can ask open-ended questions in response to what clients have shared on the form. Evans provides a few examples of things counselors can say to initiate this conversation: 

  • It sounds like your spirituality/religion is important to you. 
  • How might you envision bringing your spirituality/religion into the therapeutic work we are doing?
  • You mentioned that spirituality/religion is an important part of your life. How might it relate to the therapeutic goals we have agreed to focus on?

Evans says partnering with the client to agree on goals, including goals surrounding the client’s faith, helps builds the therapeutic relationship so it can be effective and have positive outcomes for the client.

Aziz also brings up the client’s faith during the intake process. “I ask [clients] if there is anything they want me to know about their cultural or religious beliefs and if they are looking for faith-based counseling,” she says. 

Aziz notes that about 70% of her clients are South Asian and follow the teachings of Islam, Hinduism, Sikhism or Buddhism, and about 30% are from a different cultural background or faith. So she first works with clients to help them identify their own values. “That gives me a better understanding of what they’re looking for in session, and I tend to take the counseling sessions in those directions,” she says. 

Blending faith and counseling

Once counselors assess the religious or spiritual needs of the client, or the lack thereof, they can work with the client in treatment to resolve any issues or explore new insights. Young says bringing a client’s religion or spirituality into practice should be a collaborative process that is not one size fits all. 

One approach, he continues, is to ask open-ended questions that explore the client’s thoughts and feelings around their religious or spiritual practices and traditions. For example, he says counselors could ask:

  • When or where do you feel most connected to the larger whole?
  • What brings you the greatest sense of peace in your life?
  • What rituals, if any, do you practice that bring you comfort (prayer, meditation, walks in nature, etc.)?
  • Have you thought about using these rituals or practices to help resolve problems?
  • Do you have an understanding about a higher power? How is this helpful to you?

Evans co-authored, along with Jennifer Koenig Nelson, an article exploring adapting counseling to clients’ spirituality and religion, which was published in Religions in 2021. In it, Evans and Nelson argue that using the therapeutic approach of cultural humility to incorporate a client’s religion or spirituality into practice can result in positive outcomes for the therapeutic relationship and the client’s treatment goals. Citing Joshua Hook and colleagues’ 2013 article published in the Journal of Counseling Psychology, they define cultural humility as “having an interpersonal stance that is other-oriented in relation to another individual’s cultural background and experience, marked by respect for and lack of superiority toward another individual’s cultural background and experience.”

Cultural humility “relates to positive outcomes and reduces power dynamics in the [therapeutic] relationship,” Evans says. “The openness allows the counselor to step back and have the client determine what is most salient to them, rather than the counselor pushing for the client to focus on certain parts of their identity.” 

The counselor operating from a stance of cultural humility “allows for the client to determine if spirituality/religion is something important to them [or] salient to the work they are doing in counseling,” Evans continues. The client can then decide if they want their faith brought into counseling.

In their article, Evans and Nelson suggested an adaptation to Hook and colleagues’ guidelines for integrating cultural humility into therapy that focuses on religion and spirituality. Their revised guidelines are:

  • Remain humble when engaging with clients around spirituality and religion.
  • Do not assume you understand the client’s spirituality and religion based on prior training, knowledge or experiences.
  • Explore spirituality and religion with the client to determine what is positive and what might be detrimental in relation to their beliefs.
  • Remain curious about the spirituality and religion of the client as it relates to the presenting issues and ask questions when appropriate.

Aziz finds creative ways to incorporate the client’s faith into session when appropriate. If a client is having a hard time controlling their anger, for example, she may integrate the client’s religion into a breathing and mindfulness exercise to help them learn to respond to stressful situations in a healthy way. 

In this scenario, Aziz would first ask the client to come up with a word or phrase that is connected to their faith and has a calming effect. The client must be able to repeat the word or phrase with ease. A client may choose the word “patience” as their mantra for breath exercises, for example, because it reminds them of the Islamic scripture “God is with those who are patient,” Aziz says. 

She would ask the client to relax and clear their mind of any thoughts. Once the client is settled, she would ask them to take four deep breaths in through the nose, hold for a count of six and then breathe out through the mouth for a count of six. While engaging in this breathing exercise, they would focus on repeating their mantra in their mind. This exercise is a helpful way for clients to calm their body and mind and focus on inner peace, Aziz notes. 

Asking clients to select a mantra that resonates with them makes it more likely that they will follow through with the practice on their own, Aziz says, because it helps to make the practice personal to them. And that approach works with clients whether they are religious or nonreligious, she adds. 

“If the client requested faith-based counseling, they usually gravitate toward phrases that have religious significance” to them, she says, noting that she may also talk to the client about why the phrase is important to them.

The guided imagery “wise being” exercise (see is another technique that counselors can adapt to incorporate a client’s religion/spirituality, Aziz says. This technique, she explains, allows clients to tap into their own faith and values.

Aziz begins the exercise by asking the client to imagine a safe space where they would feel comfortable having a personal conversation with someone they view as a wise being. The purpose of the conversation is to allow the client to discuss their problem or issue with the wise being without judgment and to receive guidance from the wise being on how to resolve or approach the problem, Aziz says.

“A lot of times people might pick a spiritual guide based on their faith,” Aziz says. For example, a Muslim client may select the Prophet Muhammad, a Christian client may select Jesus Christ or a Buddhist client may select Buddha.

After the client selects their wise being, Aziz asks them to imagine the guide walking toward them to begin the conversation. “It is almost a spiritual moment for them to have this conversation,” she notes. They “may have felt the presence of their spirit guide” during this exercise. And the exercise often provides clients with clarity or helps lead them to what they want to discuss in counseling, she adds. 

Aziz leaves the decision to share the details of this conversation with her up to client. Sometimes, it takes clients a few sessions before they are ready to share what they felt or experienced in that moment, she says. 

If a client chooses to discuss the exercise with her, Aziz often asks, “Why do you think [the] wise being said what they said?” Then together they process the client’s feelings about the wise being’s message and its meaning. She asks, “How are you going to incorporate [the wise being’s advice] into your life?” 

Overcoming challenges

Integrating a client’s faith into session may not be easy for some clinicians. Young reminds counselors that they don’t have to be an expert on a client’s religious or spiritual beliefs to be effective.

“Counselors don’t have to have the answers for [a] client’s faith questions,” he says. “It is an important part of faith development for people to struggle with questions that do not have clear answers.”

Young advises counselors to remember that staying present for the client, being curious about their experience and not projecting their own values onto the client can help to navigate the ups and downs of practice if they are focusing on a client’s faith or another area of the client’s life. 

Hughes says counselors must be willing to meet challenges and make reasonable mistakes when bringing a client’s faith into practice, and they must be willing to use compassion to correct themselves. But when counselors deal with religious and spiritual sensitivities, they don’t feel they have any space for errors.

Counselors don’t want to violate the code of ethics, Hughes says, but even if they’re doing therapy competently, they may sometimes ask irrelevant questions or make a human gaff. For example, he once worked with a Jewish client who often brought details about her faith into therapy. But when he attempted to define the Hebrew word “shalom” in reference to the client’s therapeutic goals, the attempt “fell flat,” he recalls.

“I have studied some of the original Hebrew and knew what I was talking about technically,” Hughes explains. But the client “corrected me from her personal understanding, and because I am neither Jewish nor living her life, she had the right to define what the word meant to her in relation to her goals.” This exchange highlights the need for communication and questions as well as the importance of never taking things for granted, he adds.

Fox, executive director of the Episcopal Counseling Center in DeLand, Florida, says navigating a client’s faith can be challenging for counselors when they realize the diversity of religious and spiritual perspectives. 

“You encounter a myriad of worldviews, practices, frameworks of meaning, [and] it can be daunting about where to start,” Fox says. It can be hard for counselors to “discern when a client’s religious or spiritual life has become unhealthy,” or if the real dangers of imposing their values onto the client have become evident, he adds.

Fox and Aziz recommend counselors find a mentor or supervisor or seek additional training if they have questions or want guidance on discussing faith with clients. “I think there’s a lot of benefit to talking to colleagues and supervisors [to get] a different opinion or view of things,” Aziz says.

Be curious

The counselors interviewed for the article agree that clinicians should take advantage of opportunities through professional channels and in their community to learn more about the diversity of religious and spiritual traditions of their clients.

“We learn best by engaging with individuals who are different from us,” Evans says. “Get out there, get to know people, … and be curious.”

She suggests attending different religious services and reaching out to local religious leaders who are open to sharing information about specific religious and spiritual practices.

“[Do] what makes sense clinically,” Evans says. “Start exploring things. … Take the time to be curious and investigate and interact with people outside [your] regular circle.” 

Most professional trainings about religion and spirituality are Christian in nature, Aziz notes, so counselors who are seeking guidance about other religious or spiritual traditions should consider reading books or researching multicultural blogs. 

Evans, Fox and Young recommend counselors take advantage of the resources offered by ASERVIC, including Counseling and Values (their official publication and one of the oldest peer-reviewed journals on the topic of spirituality and religion), their annual conference and webinars. 

Fox serves as co-investigator of the Spiritual and Religious Competency Project (, an initiative funded by the John Templeton Foundation, which aims to provide mental health professionals with basic competencies to address the spiritual and religious aspects of their clients’ lives. His team of researchers are “testing methods of training mental health professionals in spiritual and religious competence” and are tracking how mental health professionals may utilize this training nationwide. They are also “using implementation science to discover the best ways to make this type of training more likely to happen in mental health care in the future,” he says.

The project’s early research has found that more mental health training programs are open to including religious and spiritual studies, but staff lack the training to confidently teach and supervise students, Fox explains.

“Over the next five to 10 years, we are hoping that through our efforts we see this gap close so that every client who brings religion and spirituality into their counselor’s office will be met with competent help,” he says. 

Young is also hopeful about what the future holds for the integration of religion and spirituality within counseling. He says the more research that is done in this area and the more conversations that takes place among counselors, the more possibilities there are to expand the reach of religion and spirituality in clinical practice for the benefit of clients.



Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at


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