Monthly Archives: January 2023

Is Medicaid properly serving youth in foster care?

Compiled by Lisa R. Rhodes January 31, 2023

Paper cutout family with house under a Medicaid umbrella


Older youth who are transitioning out of foster care face many mental health challenges such as trauma and attachment and trust issues. In addition, they grew up in a flawed foster care that often results in the youth who have experienced multiple placements in different foster homes, overwhelmed caseworkers and poor planning for transitional living to adulthood.

Most children and youth in foster care are eligible for Medicaid, with individual states determining eligibility criteria within federal guidelines. Data from the Children’s Defense Fund shows that Medicaid covers over 99% of children in foster care and that up to 80% of children entering foster care have a significant mental health need. However, reimbursement problems associated with Medicaid often lead to a disruption of mental health services for these youth.

Q&A With Chase Chick

Chase Chick, co-founder of Pursuit of Happiness in Dallas, spoke with Counseling Today about Medicaid’s deficiencies in serving counseling agencies that work with youth in foster care and the steps his practice is taking to reform Medicaid for foster care youth in Texas and around the country.

What is the capitation rate model of Medicaid and how does it work?

The capitation rate model is a perverse idea on its face. The government, rather than implementing health care themselves, gives giant lump sums of money to commercial insurance companies called, you guessed it, a capitation rate. The insurance companies derive their profits based on what they do not spend. You can certainly draw your own conclusions about why this is a prima facie bad idea.

What are the main problems your practice has encountered under this model?

Inappropriate claim denials, unending audits, delayed payments, no payments at all, failing to enroll providers in a timely fashion. The list goes on and on. The fun part is when a counselor who pours their heart and soul into this population starts getting inappropriate claim denials and has to tender their resignation against their own wishes. What follows is a disruption of services (if we can even find a replacement counselor in time to resume services at all) with a vulnerable kid who doesn’t deserve to have their counselor quit on them. The lack of consistent counseling is precisely the No. 1 reason why these kids far too often become statistics.

What steps is your practice taking to correct these problems?

We have made numerous complaints to the Texas Health and Human Services Commission (HHSC) about the issues. The problem is that HHSC is slow to act, if they act at all, and they often side with the insurance company. When HHSC actually bothers to correctly side with us, too often the claim denials have already impacted the counselor and they have already resigned. It’s a pretty hollow feeling getting claims paid to a counselor who has already moved on. The damage is already done, but worse still, the damage to the foster kid is immense. Usually, these kids show up at psych hospitals after a suicide threat or a meltdown and the caregiver calls Child Protective Services (CPS) or the placement agency and tells them they’ve had enough and to come and get the kid. From there it’s off to a residential treatment center or sleep in the CPS offices. And from there it’s statistics time.

Anyone want to take a guess on how well a foster kid does after having their caregivers quit on them with nowhere else to go but sleeping on the floor of a CPS office? The worst part? We had a chance to get a good counselor in front of this kid who could have made a difference. We had the referral. We had the counselor. We had the kid scheduled. But instead, the capitation rate model claim[ed] another victim. Rinse and repeat.

What are your goals in bringing this matter to legislators on Capitol Hill?

We absolutely have to get the insurance companies out of the driver’s seat, especially when it comes to mental health. During one conversation with a particular insurance company, we were told we were wrong for rendering individual and family counseling on the same day, despite the fact that in addition to working with the kid individually, helping integrate the kid into the family unit is something that CPS caseworkers and placement agencies often beg us to do in order to avoid disruption.

Our legislative proposal offers a beautiful fix in that it follows the precedent of the Saint Anthony Hospital v. Eagleson decision from Illinois in correctly naming the state as the one ultimately responsible for implementing Medicaid. The kicker is that it will work out to be a revenue positive for the state, which is always a legislative concern when scoring the impact on the governmental budget.

I’m not sure if I want to get into the mechanics of how it actually works at this time because the insurance lobby is extremely well funded, but it would be a giant leap toward making sure that the days of inappropriate claim denials and other antics are a thing of the past.

We’re a great organization [that] specializes in what I believe to be a population that presents us the best opportunity to spread the most amount of good. Our counselors do exceptional work and pour everything they have into these patients. Making sure they are paid for their work rather than being cheated out of their hard-earned pay should be a priority at the top of every list.

Medicaid and Medicare combined are twice the budget of the United States military, and as such, [this] is a very expensive issue. Making sure these taxpayer dollars are respected and utilized as they should be rather than a money-making scheme for insurance companies should enrage every single person in the United States. We all live in this society together. The Medicaid program is supposed to be a tool to make sure that the most vulnerable among us have an opportunity to become a contributor to society. With the current capitation rate model, the best I can say is good luck.


Read more about the challenges faced by older youth in foster care in Counseling Today‘s February feature article, “Counseling youth aging out of foster care.”


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

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

Voice of Experience: Losing Summer

By Gregory K. Moffatt January 30, 2023

Blur photo of emotions moment of girl with flowers waiting for first summer.

Sorn340 Studio Images/

My client, a 22-year-old woman named Summer, sat across from me with a blank stare. (The client’s name and some details have been altered to protect the client’s confidentiality.) We had worked together for several months as she battled addictions, relational issues, childhood trauma and a host of other rapids she had to navigate during her relatively short life.

She described what she could remember of her most recent binge. It was a night of excessive drinking with three men she met at a club that led to a rape she couldn’t remember because of a blackout. She awoke to a gray morning lying in a parking lot. In pain, missing clothing and realizing what had happened, she blamed herself. No thoughts of calling the police or going to the hospital. She didn’t even know the first names of any of the three men.

This wasn’t the first time either. Some days, I felt that she was trying to impress me with her exceedingly risky behaviors, and other times, I felt angry — countertransference because I seemed to care more about her safety and her future than she did.

As one would imagine with any client struggling with this level of alcoholism, her life was in turmoil. She didn’t have a single stable relationship other than with me. She had lost several different jobs and been evicted from apartments twice during our time together. And on this day, in addition to the events a few nights before, she informed me her boss was considering terminating her from her current position because she repeatedly failed to show up for work.

She asked me if I would write a letter to him confirming that she was in therapy and working on her issues. It is one of the very few times I agreed to this request. With a release of information in hand, I wrote a short letter, confirming that she had been in therapy and that we were working on the underlying issues that led to her troubles at work.

In addition, I added a line I had never before written and have never written since: “If at all possible, I am hopeful that she can keep this job. It is the one stable and healthy thing in her life.”

Gratefully, the boss agreed to allow her to stay on a probationary status. She had four weeks to follow through on the conditions of her probation. I was hopeful.

Then, just one week later, Summer showed up for what ended up being our last appointment. She had failed to live up to her conditions for even a week, and she was terminated. With tears in the corners of her eyes and a shamed expression on her face, she informed me she was moving to Texas where she had a cousin who was going to allow her to stay with her until she could get back on her feet.

She left that day, and I never saw her again. I lost Summer. Given her trajectory, I wasn’t confident she would live to see her 25th birthday. It was one of the hardest terminations I’ve ever had to manage.

But, thankfully, that isn’t the end of Summer’s story. I thought of her many times over the years and wondered how I could have better helped her. Then one day, maybe 20 years later, a handwritten letter arrived in my mailbox. I recognized her name on the return address immediately.

close up of man holding envelope with a letter inside


It was a long letter, nearly three pages, and much of it detailed her life after leaving Atlanta. In short, she stopped drinking, went back to college, married, became a nurse and had three children. Even as I tell you this story, I still feel relief that she survived and learned to thrive.

But the most meaningful part of her letter was the opening two sentences: “Hi, Dr. Moffatt. I don’t know if you remember me, but [short summary of our work together] and I’ve never forgotten what you did for me.”

I know that many of my clients have deeply appreciated the work that I did with them, and sometimes they tell me to my face. Many of the children I’ve seen over the years have become thriving adults, and I’ve crossed paths with them here or there. It’s always satisfying to see their lives moving on.

But I’ve never been so sure I lost someone as I was with Summer. That letter, the last contact we ever had, reminds me that we never know how we are affecting our clients in a positive way, even if those effects come about somewhere further down the road.


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

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

What quiet quitting says about workplace mental health

By Samantha Cooper January 27, 2023

Closing the laptop at 5 p.m. Quiet quitting concept

Ivan Marc/

Everybody is exhausted. The COVID-19 pandemic, which started nearly three years ago, shows no signs of ending anytime soon. The disruption to the social norm has caused a lot of people to reevaluate their priorities, especially when it comes to the workplace.

In 2021, over 47 million people left their jobs, and this wave of voluntary quitting became known as the Great Resignation. Shortly after, people started hearing the phrase “quiet quitting.” This term is deceiving because it doesn’t refer to actually quitting one’s job. Rather it means “quitting the idea of going above and beyond” in the workplace, according to Zaid Khan, who’s viral TikTok popularized the phrase.

Quiet quitting is all about boundaries, says Kate Schroeder, a licensed professional counselor (LPC) at Transformation Counseling in Saint Louis. In fact, Schroeder says when she heard this term, her first thought was, “Oh, people are having boundaries.”

But the idea of having boundaries at work is not a new phenomenon at all. It’s just been given a name, notes Farah Harris, a licensed clinical professional counselor in Illinois.

“Your mom probably quiet quit on her job 40 years ago when she was like, ‘I’m pregnant. We need insurance. Let’s just get this job done,’” she says.

Who’s quiet quitting

This trend of quiet quitting is having a big impact on the workforce, with more people, particularly millennials and Gen Z workers, refusing to work beyond their basic job descriptions. A recent Gallup poll revealed that quiet quitters make up about half of the workforce.

Most quiet quitters tend to be white-collar, salaried workers says Briana Severine, an LPC at Sanare Psychosocial Rehabilitation in Denver. Of course, there are exceptions to this, she adds, especially in careers that expect employees to work far beyond the standard 40-hour work week to get ahead, such as a lawyer who wants to become a partner in the law firm.

And then there are careers, with workers who can’t quiet quit at all. People working in health care, for example, often don’t get to decide what duties they perform, when they work overtime or any number of responsibilities because somebody’s life depends on them doing their job and doing it well, Severine says.

Racism and biases further complicate one’s ability to quiet quit. People of color, members of the LGBTQ+ community, people with disabilities and other marginalized groups can’t easily quiet quit their jobs are because doing so would reflect negatively on not just themselves but the marginalized group they belong to.

In September 2022, The Washington Post reported that people of color were disproportionately affected by the layoffs at the start of the pandemic because of how they were perceived by management. Black, Indigenous and people of color individuals also reported higher rates of burnout than their white coworkers, according to a 2021 report from Hue, a nonprofit dedicated to building workplace equity.

As a Black woman, Harris knows too well the potential consequences: “If I show myself as just mediocre, I fall into the stereotype or biases about my race, so I actually need to be more hyper present and visible so that I can still be seen and hopefully not passed over for a promotion.”

Unhealthy work boundaries

People are tired, burnt out and they’re looking for some way to cope. Most employees are struggling to maintain a work-life balance. According to research by the Adecco Group, only 17% of workers take a sick day when they’re feeling mentally unwell or burned out and only 30% use all of their holiday time. The reason behind this is that workers often can’t afford to take off time or they’re afraid of the consequences they may face if they do, such as fewer opportunities to advance.

“In the height of the pandemic, the demographic that struggled the most were parents,” Severine says. “I think during this time it became impossible for many people to be able to go above and beyond at work, they just no longer had the capacity.”

Parents, mostly mothers, who would normally send their children to school or daycare had to take on extra childcare responsibilities at home while still being expected to maintain the same pre-pandemic level of success at work.

It became impossible for them to balance it all without majorly burning themselves out. Between advancing their career and caring for their families, it was already a challenge for mothers to ‘have it all’ before the pandemic, Harris notes. And the pandemic just provided the “perfect petri dish” for everything to go wrong.

Work stress is still an issue even for those who aren’t parents or part of marginalized group. In 2015, Deloitte conducted a survey of 1,000 full-time U.S. employees and found that 83% of respondents said work burnout negatively affected their personal relationships.

These findings indicate that something needs to change in the workplace. So how can counselors help people avoid becoming burned out, especially for those who can’t quiet quit?

Where to start

There are a variety of techniques counselors can use to assist clients and others struggling with workplace boundaries. Harris, owner of WorkingWell Daily, a consultancy company focused on workplace belonging and well-being, suggests using narrative therapy and having clients ask self-reflective questions about work such as

  • What are the stories I’m telling myself about the organization?
  • Where does work fit into my life?
  • Is my work identity my identity?
  • Is my work identity aligned with my personal one?

Asking these questions will help clients learn about themselves and find ways to define themselves outside of their career. Finding out the reason behind a client’s desire to quiet quit can also help counselors find the right way to address the issue.

Severine finds values work a useful tool to help clients. “Helping a person figure out their values, their strengths and their weaknesses can help them find a job that provides the highest amount of satisfaction,” she explains.

Severine also recommends counselors use acceptance and commitment therapy to help clients who can’t change their career find solutions. She says she often tells clients, “We have three choices. We can accept the situation as it is, we can change the situation that we’re in or we can leave the situation that we’re in.”

Schroeder cautions counselors against relying on cognitive behavior therapy (CBT), which isn’t enough to properly deal with burnout and the stress of the workplace. “Exploring our issues on a cognitive level is not going to get us to where we need to go. Feelings don’t happen in our brain. They happen in a much different part of us,” she says. “Feelings are not cognitive processes; they are energetic responses to what’s happening in our environment. Feelings happen in your body and in your heart, not your brain.”

“Since quiet quitting [and] burnout are essentially about someone who has blown through their own boundaries around what they need in their life to be happy and satisfied, we have to address these deeper issues in a noncognitive and experiential way,” Schroeder continues. Because issues with boundaries are related to childhood experiences, counselors need to be able to access these issues on a deep, somatic level so their clients can truly heal.

She finds Gestalt and somatic therapies to be more effective than CBT because they focus on clients accessing and connecting to feelings, which helps them integrate their feelings and transform.

“Transformation happens when someone can integrate on the energetic level what’s happened to them,” Schroeder explains. “And cognitive approaches will never be able to help someone integrate emotional experiences in the deep way necessary for transformation. … CBT approaches are strictly cognitive in nature and only address the rational, logical, linear thinking parts of your brain. …[They] are far more about understanding than about deep transformation.”

Learning how to communicate one’s feelings to coworkers and bosses may also help relieve some work-related stress. Sometimes counselors overlook simple solutions such as assertiveness training and communication skills in work-related situations, Severine notes. “We spend 40-plus hours a week with our boss and our coworkers so oftentimes if those relationships are unhealthy, it’s going to be dissatisfying,” she says.

When to quiet quit

One way counselor can determine why a client wants to quiet quit is to explore how intertwined clients’ work identity is with their own sense of self, Harris says. She finds that narrative therapy, as well as CBT, work well in unraveling these ties. For example, she may ask clients, “What are the thoughts about why you want to quit your job? What beliefs do you have around work? Where did that come from?”

The idea is to use these therapies to figure out why the client feels the way they do. She really wants clients to dig into the why they’re quiet quitting, so they can figure out whether the solution is leaving one company for another or going down a different route completely. She sometimes asks, ““Before you send that resignation, do you really want to quit this company or do you just not like your job?”

“As clinicians, we really need to help our clients tap into naming those emotions, being able to recognize how that emotion is showing up in their body,” Harris says. Helping clients become more emotionally fluent and in tune with what their body is telling them (such as if they get a certain pain every time they pull up to their office) will help them make a decision.

Employees don’t quit jobs; they quit bosses, Severine stresses. Workplaces can help is by acknowledging that employees should be given a lot of say in how their workplace functions. In addition, giving employees more control over how and when they work will make them more engaged in the workplace and make them less likely to quiet quit.

What most employees need, Severine says, is flexibility. For example, if an employee has to drop their child off at school at 9 a.m. but they’re also expected to be at the office at the same time, then giving them an extra half hour to get to the office (and letting them work a half hour later) could fix an issue that is causing them stress.

Quiet quitting can have many benefits if people do it for the correct reasons, such as taking care of their health or of a family member, instead of just doing it because they hate their job, she adds.

Schroeder says that unless someone is in a toxic situation, quiet quitting should not be their go-to move. If someone is slacking off at their job because they feel the job is overwhelming or difficult, then that issue may still be there if they start a new job. Instead, they need to figure out why they’re slacking off and then address that issue, she says.

Often, the underlying reasons behind quiet quitting revolve around the need for people to set better boundaries, which can help them create a healthier work-life balance, Severine says. Setting boundaries takes a lot of effort. For some, it can mean improving time management skills, so they don’t have to work overtime, or it may mean they don’t do extra work on the weekends or holidays, she adds.

“If you are quiet quitting over hating your job, I think that quiet quitting will likely do nothing to improve that,” Severine says. “Getting clear about what is the problem and being able to effectively communicate that to leadership to see if there are solutions to be found would be much healthier. Or using that information to find a job that would be better suited and lead to more satisfaction.”


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.

Does your personality make you more vulnerable to abuse?

By Avery Neal January 26, 2023

Katherine (pseudonym) sits before me, meticulously dressed and exuding confidence. She makes great eye contact, and within minutes of our meeting, she has informed me of her high-powered position at one of the top law firms in the city. She is assertive in her responses, and I am left without any question that this woman is brilliant.

As our session unfolds, I find out that Katherine has come to see me after having left her husband following years of abuse and deceitful manipulations. As she described the last incident — how he pinned her against the wall, almost choking her, and then threw her across the room — I can hardly believe that this self-assured, outspoken and composed woman in front of me has been the victim of abuse.

After years of listening to clients share their stories about how they have endured aggressive and controlling relationships, it occurred to me that we’ve got to throw out our misconceptions of abuse and start paying attention to the reality of abusive patterns.

Most important, abuse is not just physical violence. Although physical and verbal abuse are usually the easiest to recognize, psychological and emotional abuse are more destructive to a person’s psyche, physical health and mental health. Psychological and emotional abuse mostly go unrecognized because the person is left without visible bruises. There are many abused people who have never been harmed physically, which leaves them to question themselves rather than identifying the abusive dynamic in their relationship.

And it’s not simply the insecure, meek woman who finds herself in the throes of an abusive relationship. It’s the woman who graduates with distinction from her Ivy League school or the selfless housewife who dedicates her life to her children. It’s the male executive who is ashamed to admit that his wife physically attacks him.

There is no way of telling if the person sitting next to you is being severely mistreated and manipulated by their partner. There are, however, some defining characteristics that make a person more vulnerable to being abused. It is important for people to know what personality traits make them more susceptible to being manipulated and abused so that they can begin to protect themselves.

Are you naive or inexperienced in relationships?

People who have not dated much or who have not had many romantic partners are more likely to end up in a controlling relationship simply because they don’t have other relationships with which to compare. They believe that what they are experiencing in their relationship is normal even if it doesn’t feel right.

The widely believed notion that only people who grew up in abusive families seek what is familiar and tend to end up with abusive partners gives many a false sense of security. Those who have not grown up in an abusive home think they will be equipped to know what to look out for in a partner. Although people from abusive homes are more likely to overlook abusive behavior in their partners, this is only part of the story — a very small part that has left many people falling unsuspectingly into the hands of abusive partners.

Because abuse occurs gradually, many people find themselves committed to their partners before they even have an inkling that something is amiss. Therefore, it is critical not only to know the early warning signs of an aggressive or controlling relationship but also to know how to protect yourself if you find that you fit the profile of someone who is at a higher risk for being abused.

Are you overly responsible?

People who take on more than their fair share of responsibility — be it bearing the brunt of financial burden, investing more in the family or carrying the emotional weight in the relationship — tend to be more likely to end up with partners who exploit their sense of responsibility and work ethic. It is not uncommon for one person to find that they’re doing most of the heavy lifting in the relationship while their partner sits back and watches, completely unconcerned.

In addition, those who tend to apologize even when they haven’t done something out of line are, in fact, taking responsibility for whatever mishap has taken place. While it is admirable to have the humility to apologize and “own up” if you’ve done something wrong, it makes it easier for an abuser to take advantage of you if you constantly apologize when you haven’t done anything wrong. So if you tend to be the overly responsible type, both in practice and emotionally, be sure to find a partner who contributes equally to the relationship.

Are you highly empathetic?

Highly empathetic people are more likely to fall for someone who plays the role of the victim, a common personality trait in most abusers. A person with a great deal of empathy accepts when their partner tells them that past childhood trauma is the reason for the abuse and that they simply can’t help it. The highly empathetic person is also more likely to cave after standing up for themselves when an abuser cries, apologizes, begs them not to leave or promises that “it won’t happen again.”

A person’s greatest strength can also be their greatest weakness, and this is certainly the case with empathy. If you’re an empathetic person, be aware that abusers know they can appeal to your empathy and compassion to get what they want. You must learn to protect yourself from being manipulated by someone who does not have your best interest at heart. Focus on relationships with people who do not exploit your empathy or coerce you into tolerating behavior that you should not have to withstand.

Do you avoid conflict at all costs?

Those who suppress their feelings to prevent others from getting mad at them are more likely to end up being abused. People who avoid conflict experience extreme discomfort if they believe that someone is mad at them. Their fear of disapproval or discord leads them to give up their need so as to avoid confrontation at all costs. These people, who typically describe themselves as peacekeepers, are far more likely to end up with an abuser because they are an easy target.

The conflict-avoidant person takes pride and feels settled when harmony is restored, so they work harder and harder to keep the abuser happy. The problem is that no matter how hard they work in their relationship, they alone cannot change the dynamic. Far more likely, they will completely lose their sense of self in the process of trying to change the relationship, eventually succumbing to keep harmony in the relationship.

Although there are tremendous benefits to being a peacekeeper, the problem arises when you completely sacrifice yourself to keep your partner happy. It is important to practice asserting yourself and your needs and to have a partner who allows you to do so without punishment.

Trust your intuition

I encourage people to trust their intuition if something doesn’t feel right in their relationship. Far too many people suffer in silence because they are embarrassed to admit that they have ended up in an unhealthy relationship or that the cost of getting out of the relationship seems too great.

Remember, abuse is gradual, which makes it even more difficult to see objectively. People try to convince themselves that if they could just get the relationship back to what it was, everything would be all right. But it will not be because abuse escalates over time.

In the case of Katherine, her personal life now matches her professional one. It wasn’t an easy journey, but she has learned to recognize the early warning signs of an abuser, to speak up for herself and to not excuse bad behavior. Her life now is filled with people she respects and who respect her in return. And she has the freedom to make her own choices — without fear.


headshot of Avery Neal


Avery Neal holds a doctorate in psychology and is a licensed professional counselor, a practicing psychotherapist, and an international author and speaker. In 2012, she opened the Women’s Therapy Clinic, which offers psychiatric and counseling support to women. She is also the author of If He’s So Great, Why Do I Feel So Bad?: Recognizing and Overcoming Subtle Abuse, which has been translated and published in 12 languages. Contact her through her website at


Read more about how counselors can recognize and treat psychological abuse in Avery Neal’s article “Identifying psychological abuse” in the February issue of Counseling Today.

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.

Generational trauma: Uncovering and interrupting the cycle

By Bethany Bray January 25, 2023

A young Black child sitting on a couch with her mother and father. The mother has her arm on the child's shoulder. A person sit across from them taking notes.


Ashlei Petion, a licensed professional counselor (LPC) and assistant professor of clinical mental health counseling at Nova Southeastern University in Florida, noticed a common pattern in the counseling work she did with adolescents during her master’s internship. Her young clients would often talk in sessions about challenges and friction at home, but whenever Petion looped the clients’ parents into the discussion, they said they were simply parenting their child in the same ways their own parents had done with them.

Petion said she heard this over and over, and it made her realize that the challenges that her adolescent clients were facing were “bigger than the client who was sitting in front of me,” she says. “It’s part of their entire family and, in turn, their culture.”

This experience as a master’s intern sparked Petion’s interest in researching generational trauma, which eventually led to her doctoral dissertation and area of specialty as a counselor.

Generational trauma is complex, but counselors must remember that it doesn’t mean that there is “something inherently wrong with an individual [client],” Petion stresses. “It’s a collection of traumas that have been experienced by their ancestors, passed down, and it’s affecting them to this day. They are battling something bigger than them[selves].”

Taking a broader view of trauma

A common — and perhaps deserved — critique of the definition of trauma traditionally held by mental health practitioners and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) is that it is too narrow and doesn’t acknowledge the many different types of trauma, says Rachael Goodman, an LPC and associate professor at George Mason University whose area of specialty is trauma.

Counselors and society at large, including clients, may conceptualize trauma as the result of a single event or events that an individual has experienced personally. Trauma, however, can take many forms; it can be ongoing, vicarious, complex, generational and systemic, notes Goodman, the academic program co-coordinator and the Council for Accreditation of Counseling and Related Educational Programs (CACREP) liaison for the counseling program at George Mason University.

Because of this narrow definition, other types of trauma, including generational trauma, can be overlooked and outside the awareness of both clients and counselors, especially during the client assessment, diagnosis and treatment planning process, Goodman says. Also complicating the issue is the disparity that exists for clients from minoritized cultures, who are more likely to experience generational trauma based on systemic oppression and related issues, she adds.

For some clients and counselors, societal oppression and historical/cultural erasure may keep them from linking presenting issues, such as trouble in relationships or problematic coping, to challenges or trauma that clients haven’t experienced themselves, but which affects their family and community, Goodman notes. Counselors’ role “is to bring that [trauma] into consciousness and work with the client to address it,” she says. “It can be very powerful for the client to have their experience acknowledged and framed as a ‘legitimate’ source of trauma, when often systemic or ‘nontraditional’ forms of trauma are ignored or excluded from mainstream assessment and practice.”

“Clients often report that it feels like [a weight] sitting on their shoulders,” Petion agrees, “and they feel like they need to interrupt this and not pass it on.”

Like Goodman, Petion feels there is sometimes a knowledge gap among counselors regarding generational trauma. There’s just no way a counseling program can cover everything fully, including the complexities of trauma, in a two-year master’s program, she says. In addition, many of the textbooks and materials counselor education programs use to teach students about trauma have a Western viewpoint and do not cover historical and generational trauma, she adds.

This means that it’s essential for counselors to seek out additional training and information on generational trauma and best practices for treating it if it’s coming up within their client population, stresses Petion, a member of the American Counseling Association and co-author of the recent Journal of Counseling & Development article, “‘Battling something bigger than me’: A phenomenological investigation of generational trauma in African American women.”

Petion admits that it can be hard for those who haven’t experienced generational trauma to grasp just how challenging it can be to live with — or overcome — this type of trauma. “Changing just ourselves [in counseling] is really difficult, but then adding in other people and your whole family — it’s really difficult to ignite change,” she says, “but we know it’s possible.”

Identifying generational trauma

The first step to identify generational trauma is to ask the client to talk about their family history, including their relationship dynamics and how their family interacts with each other and the world around them, says Jordan Mike, an urgent care counselor at the counseling center at Vanderbilt University who is working on earning a professional counselor license in Tennessee. However, the most important thing a counselor can do during this process is to simply sit with and support them and “truly listen” as the client tells their story, he notes.

Generational trauma is an area of research for Mike, a third-year doctoral candidate in counselor education and supervision at the University of Florida, but it’s also something he personally witnessed growing up as a Black man. He says he also sees its effects in the concerns of the students, faculty and staff he counsels at Vanderbilt.

It can be an aha moment when a client realizes that an issue they are struggling with is actually something all of their family has suffered with as well, Mike says. And now as counseling becomes more available and accepted, he hears more clients are saying, “Hey, this is not a ‘me’ issue; it’s something that has been trending in my family for decades and hasn’t been addressed or helped.”

Clients who are affected by generational trauma may exhibit some of the same behaviors and symptoms as people who have experienced a traumatic event directly, including strong emotions such as anger, sadness or anxiety, notes Mike, an ACA member. Fear, including irrational fears, and distrust are common emotions among clients who are affected by generational trauma, he notes, particularly intense fear, anxiety, avoidance or distrust of places, communities, situations or systems that they’ve never experienced or have been to or through themselves.

The crux is to uncover where these feelings originate; if it’s something that they’ve internalized from their family or community, then it can indicate they have generational trauma that needs to be addressed, Mike says. For example, a client who expresses fear or distrust of law enforcement or medical care may not have a personal experience that prompts that fear. When asked where they think the fear originates, they may answer, “I’m not sure but this is what I’ve always heard; this is what my parents say and my community says,” he explains.

Desiree Guyton, an LPC with a private practice in New Jersey, says that generational trauma can also cause clients to harbor feelings of shame and negative self-worth. She guides these clients to talk about their family of origin, and where their feelings of shame might have originated. Clients who are affected by generational trauma often find that they stem from cultural messages they have internalized, Guyton says.

Generational trauma can also become apparent if a client talks about what isn’t addressed, acknowledged, processed or talked about in their family, culture or community, Mike adds. Cultures of silence are often adopted as a protective or coping measure, he says, but this can also mean that “there are so many things that can go untalked about, unsolved and unresolved.”

Because this trauma often goes unacknowledged, coupled with the fact that clients may struggle to pinpoint or name their generational trauma, Mike finds that it can be helpful to prompt clients to think of major events in their family or community, including things that were “hard to get through,” such as violence or loss, in addition to asking about family dynamics. He often asks clients, “What are some things that you have come together for as a community or family?” or “What is something that left a lasting impression?”

The counselors interviewed for this article agree that delving into a client’s family dynamics and history, including the use of timeline exploration activities and genograms, is helpful to uncover and distinguish clients’ generational trauma from other trauma experiences or mental health challenges.

Goodman developed a genogram tool that counselors can use to screen for intergenerational trauma in clients, which she wrote about in an article published in Counselling Psychology Quarterly in 2013. It can be particularly helpful for clients to write out aspects of their history or express them visually (e.g., making a collage out of images) to help them “get it out of their head,” look at it, and find patterns of trauma as well as resilience and persistence, she says.

Go slow

Guyton and Goodman both stress that counseling work with clients who have been affected by generational trauma needs to be client led and only go as far and as deep as the client is comfortable.

“Give the client time to build trust with you. They may not be willing to share and talk about [this topic] right off the bat. They may need you to demonstrate that you are someone who can be trusted, someone who will believe them,” says Goodman, an ACA member and representative on the ACA Governing Council.

Goodman notes that some clients may want to do a deep dive into processing the historical origins of their trauma while others may simply want to acknowledge it and focus on other work, such as learning coping tools for everyday life. For some, healing and meaning making can also involve engaging in social action, supporting their own family members or embracing a helping role within their community, she adds.

“The goal is for our clients to be able to live the life they want to live,” Goodman continues. “It’s not up to me to tell them they have to revisit their entire family history. … I’m interested in finding out what ‘living a meaningful life’ means for each client and helping them get there.”

Similarly, Guyton, an ACA member and co-author of the workbook Healing the Wounds of Generational Trauma: The Black and White American Experience, has had clients who traveled to speak with extended family members to learn more about the trauma, context and life stories of their ancestors, whereas others are not comfortable doing so. She herself has found it healing to trace her own family history to its enslavement and connection to the descent of slave owners.

Counselors must also be sensitive to the ways generational trauma can dovetail with systemic issues such as racial trauma and oppression. For example, a counselor can help a Black client who is activated by news coverage, such as when George Floyd was killed by police in Minneapolis in May 2020, to process how they feel — including grief and loss — and how it connects to their trauma history, Guyton says.

“Not all grief is traumatic, but all trauma has some feelings of loss,” she adds.

Guyton, who also leads groups and does trainings on racial conflict, trauma and healing through the nonprofit Quest Trauma Healing Institute in partnership with Trauma Healing Institute, advises counselors to listen when clients talk about their family unit or abuse history “because for people of color there is often more to it,” she says. “There is usually a connection to what it is to be an American and how they feel as an American.” Also, the field of epigenetics, she adds, teaches us that the historical trauma reactions can be passed down to next generations.

Counselors may also need to work on multiple challenges with these clients at once, Guyton says. “For those whose [generational trauma] comes out in session, we need to take it very slow, because often they are struggling with another presenting issue or other trauma. Once it surfaces, I focus on it as much as the client leads and wait until they’re ready to process it. I want to also be sensitive to the other types of trauma” they’re dealing with, she explains.

Both/and approach

Guyton has developed an approach that uses a combination of cognitive behavior therapy, narrative therapy, genogram and some guided imagery work to help clients identify the generational trauma being passed down to them and gain the skills to interrupt transmission to the next generation. She also starts by offering psychoeducation on trauma (and generational trauma) and asks questions about how and where the client may be experiencing the effects of trauma physically in their body.

Goodman agrees that counselors may need to vary their counseling approaches to address the interrelated concerns and challenges these clients are facing. She encourages counselors to take a “both/and” approach to address clients’ immediate needs (i.e., coping mechanisms to calm down when activated or social services to address stressors of daily living) as well as deeper work to address their trauma from a culturally sensitive, intersectional perspective.

“There are a lot of different ways of approaching this, but I tend to believe that ‘one size fits all’ is not going to do it,” says Goodman, a past president of Counselors for Social Justice, an ACA division. “Instead, [counselors should] think broadly of a both/and intersectional model that addresses the underlying and systemic causes of trauma.”

Goodman has past experience doing community engagement and support work on a Native American reservation. Some parents that she worked with often expressed feeling like they did not have enough tools or knowledge on how to parent, which placed stress and strain on family relationships, she recalls. Some of these parents had been removed from their family home as children and sent to boarding schools where they experienced trauma, so they never had the experience of growing up in a supportive, loving family. The situation left many of the parents with intense feelings of shame, fear and generational trauma, Goodman says.

In turn, these parents and their children were living with generational trauma as they struggled to maintain family bonds, she adds.

She found that these parents wanted to learn parenting skills in counseling to meet their immediate needs and support their children, but they also needed deeper work to process the trauma of their experience at boarding school, where they weren’t allowed to speak their native language or wear their native dress and, in some cases, suffered abuse.

In addition to cultural sensitivity, Goodman urges counselors to keep a focus on hope with clients who are living with generational trauma. At intake, explore not only their trauma history and challenges but also their strengths, resources and things that give them hope, she advises.

“Hope and having connection [in relationships] is so important” for these clients, Goodman stresses. “These problems are huge and have huge impacts, so helping our clients persist in spite of these barriers is really important.”

Supporting clients

Counseling to help clients acknowledge and unpack their generational trauma must be culturally sensitive and tailored to each client’s different combination of needs. The counselors interviewed for this article offer the following insights to support clients in this process.

The miracle question. Mike finds that it can be helpful to start discussions by prompting clients to consider the “miracle question” and imagine or visualize a world where their challenge or problem (in this case, generational trauma) is completely removed. He suggests asking the client, “What would it be like if you didn’t hold on to these feelings, or this pressure wasn’t there?” to spark thought and discussion about the big picture and larger issues connected to their challenges.

A client, for example, may be the first person in their family to attend college and feel intense pressure about choosing the “right” major. Mike says he would support the client in their decision-making process and help them gain perspective and clarity by asking, “What would be different for you if everyone in your family had gone to college or if there was no pressure and you could do whatever you want?”

“This [miracle question] gives them permission to not have to consider all the things that weigh on them, for once,” he explains.

Communication and boundary setting. Petion led a support group for Black women who had experienced generational trauma as part of the research for her doctoral dissertation. One of the things the group members found helpful, she recalls, was building communication and boundary-setting skills that they could use with their family members. The group talked a lot about how to remain calm, manage their body language and keep a problem-solving (rather than blaming) focus when having “brave dialogues” with family members about behaviors and patterns that had been adopted because of generational trauma, she says.

Petion also equipped them with ways to use “I” statements to voice their feelings. Instead of saying, “You really hurt me when you did this” to a family member, a client could say “I was really hurt when you did this” or “I felt this way,” she says. The purpose of shifting from “you” language to “I” language is to minimize or eliminate feelings the other person may have of being attacked or blamed, Petion explains. “I statements help us to take accountability for our own actions and feelings, speaking for ourselves instead of projecting onto the other person,” she says.

One group member grew up with a mother who didn’t believe children should express their feelings, Petion recalls. Having her feelings dismissed throughout her entire childhood was chronically traumatic for her. In group, this participant was able to practice having an assertive yet productive conversation with her mother to explain that she was using a different method to parent her own child because she had been hurt by her mother’s approach during her childhood, Petion says.

Guided imagery techniques. When a client is processing their generational trauma, guided imagery, including the “empty chair” technique from the Gestalt method, can be a way to ask questions and speak to family members or ancestors who are no longer alive, Guyton says. This technique was beneficial for one of Guyton’s clients who described “harsh” treatment by her grandmother growing up, and now as an adult, she was struggling with feelings of shame and negative self-worth, poor choices of intimate male partners and parenting stressors. This client’s desire not to pass on her trauma reactions to her children, as well as her anxiety about being poor and abusive, is what led her to seek counseling, Guyton adds.

When the client began to explore her family history, including the pressures her grandmother faced as she emigrated from her Caribbean homeland to the United States, she realized “I need to talk to her,” Guyton recalls. (The client had recently traveled to her grandmother’s home island and spoken to extended relatives to learn more about her grandmother’s life story and context.)

Guyton used guided imagery with this client and began by asking her to picture her grandmother and describe what she was seeing. Guyton then prompted the client to talk to her grandmother and share how she was feeling. The client responded by saying, “I see you, Grandma. I see you in this context. I’m understanding more now, and I wonder what it was like for you to raise all of us through poverty, sexism, racism and physical abuse. I want to know what it was like.”

These types of conversations can help a client process their connections to trauma and find closure. For this client, “being able to close her eyes, breathe, remember and picture her [grandmother] in a different way” and think of her difficulties in context moved her toward forgiveness and healing, Guyton says.

Case management. Counselors sometimes shy away from conversations or tasks that feel like case management, such as helping a client enroll their child in school or navigate the bus system to commute to work, Goodman notes. However, this type of support can be particularly helpful and needed by clients who are affected by generational trauma, especially those with refugee or immigrant experiences, she says.

“You may get pushback from a supervisor because it’s outside of counseling,” Goodman says, “but what I’ve found is that these experiences are really important.”

Do your own work. Processing a clients’ generational trauma in counseling involves inviting them to talk about their experience, but the onus should never be on the client to teach the counselor about their culture and history, Goodman stresses. It’s vital for counselors to seek out consultation with peers or do research on best practices to treat a client who comes from a specific community or cultural group, she says. There are treatment methods that are tailored to meet the specific needs and trauma experiences of different cultures and that use culture-centered, decolonial and liberatory approaches, she notes. Counselors just need to seek them out.

Similarly, practitioners must do their own work to become comfortable broaching the subject and discussing cultural issues and generational trauma with clients who come from different — and possibly less privileged — backgrounds than their own, Goodman continues. She encourages counselors to gently name any differences that exist in the counseling room, using questions such as “When counselors and clients are different in their identities, it can be helpful to name that and to think through how we might work together. Since we have some differences in our identities, what challenges might we have in working together?”

Goodman urges counselors to broach this subject not only at the start of counseling work with a client but also with regular check-ins throughout the relationship. “We [counselors] each have to figure out for ourselves language that is genuine for us” to foster these conversations, she says. And counselors need to “be willing to say, ‘I’m hearing some hesitancy, and I wonder if you have any concerns about talking to me about this.’”

Don’t make assumptions. Counselors should be listening for the signs of generational trauma in each client, regardless of their cultural background, Petion adds. “Privileged groups can still have generational trauma, even though it’s not talked about as much,” she says. “Anyone who has experienced trauma can pass it down. … Don’t make assumptions. This affects us all in some way, shape or form.”

Healing in connection

In her book All About Love: New Visions, the late bell hooks wrote, “Rarely, if ever, are any of us healed in isolation. Healing is an act of communion.”

Petion says she shares this quote often when talking about generational trauma with clients and colleagues. The truth is that clients do not live in a vacuum; they can work toward healing individually in counseling but will ultimately return to live within their culture and family system, she notes.

“Generational trauma is just that — an individual whose trauma is perpetuated within family and culture,” Petion adds. So, with this client population, practitioners must “think beyond the individual sitting in front of us” in counseling, she stresses, and focus on how they are healing in connection to their family and community. “That’s really where we interrupt the transmission of trauma,” she says.

At the same time, counselors should remember that it may not be the client’s role to “fix” or heal their family or community, Mike cautions. “They may need to make peace with healing themselves without taking on entire systems,” he says.

Generational trauma “can be a biological thing, an emotional thing, a social thing. … Trauma changes our chemistry; it can change how we interact with other people, … who we are and even our gene expressions,” Petion says. But “counseling offers the space to relearn that [and] a space where clients are heard and validated.”


Bethany Bray is a former senior writer and social media coordinator for Counseling Today.

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.