Monthly Archives: April 2023

Voice of Experience: Building a career path

By Gregory K. Moffatt April 27, 2023

Hand arranging wood block stacking as step stair

Monster Ztudio/Shutterstock.com

I started my career in 1983. Over the years, I’ve applied my skills in many areas. Here are a few: I have worked in private practice; consulted with businesses and schools; wrote more than a dozen books; consulted with authors, actors and directors; wrote regular columns for various publications; taught at the FBI Academy; and worked as a profiler for many years. The purpose of this article is to show you how a career is built. I did nothing by accident or luck. I hope this snapshot of my career will inspire you to pursue your goals.

After finishing my master’s degree, I opened a part-time private practice. I did general practice, but my passion was working with children. I knew over time I would develop my skills and reputation to where I could focus solely on children — and that eventually happened.

However, in the 1980s, there were few resources for those who wanted to do play therapy. I read every book I could find, continued my education beyond my master’s degree, and joined the Association for Play Therapy (APT). I went to the APT conference every year for years, soaking up everything I could learn from experts in the field. At the same time, I was meeting people and doors were opening for me.

When I finished my doctorate, I wrote my first professional article. I had previously done some research for an issue related to stalking (something that wasn’t even in the vocabulary of the average person prior to 1990). Additionally, I was intrigued by the potential causes of a series of shootings by U.S. Postal Service employees in the 1980s. My article addressed assessment of risk of violent behavior.

That article ended up on the desk of the former director of the FBI who had approved the original profiling research at Quantico, Virginia, where the FBI Academy is located. He called me in and asked if I would be interested in doing some training on the subject. We worked together for several years, including a decade in which I taught several times per year at the FBI Academy. That relationship also led to a very long consulting job with Delta Airlines and numerous other businesses.

I began publishing books, and almost immediately, my consulting jobs increased. I worked with famous writers such as New York Times bestselling author Lisa Gardner, who has become a very close friend. It also led to consulting work with actor/director Tyler Perry. Each writer or actor was seeking my insights as a violence expert and profiler so they could develop their characters realistically.

Over time, I moved through the ranks as a college professor, from instructor to full professor. Today I am the dean of the College of Social and Behavioral Sciences at Point University, where I have served for almost 40 years.

I also began working with an agency that sent scholars around the world to colleges that needed their expertise. I eventually taught undergraduate and graduate students in more than 30 countries, sometimes literally teaching in a grass hut, as I did in both the Philippines and India. These experiences taught me many things and helped me to develop many lasting relationships. I even received a personal invitation from the president of Rwanda to train counselors to help victims of the genocide there.

Public speaking, writing, profiling, working with clients and providing supervision are just a few of the activities that rounded out my life for many years. Relationships with my professional associations also opened doors for me. I continue to serve as the editor of our state professional journal and was appointed just over a year ago to the Georgia Composite Board of Professional Counselors, Social Workers, and Marriage and Family Therapists.

I’ve never had fewer than two or three jobs since I was in the fifth grade, and I have worked very hard. Working multiple jobs has meant that I had to cut out some things. I don’t watch much TV, and my social life is minimal. But I don’t regret a single thing that I’ve done in my professional life, and despite being busy, I always had time for my children. In fact, each of them traveled with me multiple times on my international trips.

This is a short version of my career path, but here are the lessons for you. First, focus on the end game — where you want to be in 30 years — and work backward from there. Accept opportunities that move you in that direction.

Recognize open doors when they present themselves. I worked for 10 years as a consultant with Delta Airlines, and they never paid me a penny. But my association with them and the doors those relationships opened earned me thousands of dollars over time.

Recognize your deficits. I knew I wanted to be a child therapist, and I knew I had to be my own educator. I did the same thing with profiling. Professional associations are critical in this developmental process.

Finally, don’t be afraid to chase your dreams. One of my former professors said to me often, “Greg, I never worked a day in my life.” He loved his job, just as I do. And like my friend, I’ve never worked a day in my life.

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

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

The protective side of anger

By Peter Allen April 26, 2023

a person covering their face with a yellow pillow; they are squeezing it hard like they are yelling into the pillow

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Many people would probably use the well-known phrase “anger issues” to describe themselves or someone they know. As counselors, we often find utility in addressing a client’s anger in session as part of the healing process. Anger, along with anxiety, seems to be one of the few emotions we are supposed to “manage” versus enjoy, explore or simply experience. This is probably because people have done some truly horrible things while being angry, so we possess an innate, ancestral understanding that an angry human is a potentially dangerous one. So anger is deeply connected to danger in our minds.

We also understand that people get into trouble not because they feel angry but because they behave or act in unsafe ways. Even for experienced clinicians, sitting with an angry client can be frightening. We are often inherently worried not about what clients feel when they are angry but what they will do, so we tend to focus our strategies on behaviors. After all, it is the behaviors that do the damage we can see and feel.

This focus on behavior in treatment is rational, but it may also be based in part on our collective, societal anxiety about anger, which is betrayed in the English language itself. Words such as rage, livid, fury, wrath and apoplectic are evocative and bring to mind many negative connotations. I think we can all agree that being near someone in a rage sounds scary. We pay close attention to anger because it can become a threat to us. These synonyms illustrate the different qualities and textures of anger that we can feel. To be irked is quite different than to be enraged, for example.

Anger is a special emotion not only because of all the different words we have for it but also because of how afraid we are of it. People are often so scared of their own anger that they don’t act on it. They fear what they might do. Will they lose control and say hurtful things or commit a crime? They truly don’t know. So they go to great lengths not to act. Others are stuck in cycles of overreaction and harmful behaviors, which can be a terrifying experience. And for some people, being angry is the same as feeling out of control. Thus, regaining control is often an important part in helping people to navigate their anger.

Just because anger has the potential to become dangerous behavior, however, doesn’t mean that it always will. In counseling sessions, we can begin to identify ways in which our clients’ anger is protective, and then help them navigate their anger with greater skill when it shows up.

Not all anger is bad

Understanding the connection anger has to danger is important when we are trying to help clients who are struggling with this issue. Anger can also be deeply connected to the protection of ourselves and our loved ones. Anger has been used in warfare, combat and defense since the dawn of time to give people courage, energy and motivation when they need it most — in survival situations. It has been the precursor to violence for so long that they are often intertwined in our psyches.

It has also been the precursor to numerous positive and deeply consequential social movements and changes throughout history. Anger has sparked revolutions and removed despots and tyrants from power. So how do we know if our clients are experiencing the kind of anger that hobbles them or is powering them to change something for the better? We won’t, of course, unless we are actively talking about it. It is important that we try to figure it out with them. It will be difficult for our clients to recognize or let go of anger if they feel they are in danger (real or perceived) and view anger as a form of protection.

Most of the people coming into therapy for help with anger management have likely experienced numerous negative consequences because of their anger, but some have also experienced positive outcomes. I had a client who was a middle-aged man, and he was furious at his father because he had abused him terribly as a child. His anger compelled him to stay away from his father for decades, so there could not possibly be a physical threat. He feared that if he “softened up” and let go of this anger that he might let his father back into his life. His anger formed the core of his resolve to not have any contact with his father.

In his case, the anger had served an incredibly valuable purpose: It protected him from receiving any more abuse from his father. But the following things were also true. First, he had been physically safe for many years now. He lived hundreds of miles away from his father, and he was much stronger and in better physical condition than his father. Second, he was getting tired of being angry so often.

It is challenging when we encounter people who have greatly benefited from their anger. This client’s anger was almost like a transitional object — it had brought him some comfort but now was starting to feel restrictive. For him to be able to move on, he first had to realize that he didn’t need to be angry to maintain a healthy boundary with his father. He figured out he could maintain this distance with equanimity. He hadn’t seen his father in years and didn’t plan or expect to. We used cognitive behavior therapy to help critically examine his beliefs around his anger being protective. Was he really in danger or was he safe now? This helped him realized that he was in a good position and could relax a bit.

Of course, he still felt angry at times about the past abuse, but he no longer had to constantly exist in that state. He didn’t have to achieve complete ease with everything that had happened to him; he just needed not to be consumed by his anger over it anymore. And when he felt his anger returning, he used his own self-directed internal dialogue to calmly remind himself that he was safe.

Be curious about anger

Because there is a lot going on beneath the surface when people get angry, counselors can help clients explore these underlying reasons in session. For example, anger can stem from a long history of being abused, and that type of anger will look and feel different from the anger that comes when someone is experiencing institutionalized racism or sexism. Someone else might feel angry because their spouse is having an affair, and sometimes people feel angry without knowing why. Thus, the texture and history of one’s anger is critical to our understanding and approach to it.

Anger arises from an infinite number of situations, but we can zero in on two main conditions that often make people angry:

Something is happening that they think should not be happening.
Something is not happening that they think should be happening.

It’s also important to note that not all anger is based on our cognitions. The anger that arises in survival situations is not really based on any conscious beliefs; it is a way to access instantaneous energy for attack or defense. Our expectations are not really coming into play because there is no time for that. It is our survival system activating, just like it’s supposed to. This does help us to survive but becomes problematic when deployed too broadly.

As counselors, we need to be curious about clients’ anger. For example, a person who has anger management issues may perceive numerous threats in their environment. These threats need to be identified. Is it a person? A place? A memory? It may take some digging, but if we bear in mind that a client is keeping a huge reserve of energy and resolve ready to go whenever they think about that person or situation, then they must see the person or situation as meriting that level of response. That’s significant. They are signaling to us that their anger is necessary for something in their environment. Clients will sometimes identify threats and, in the process of identifying them, quickly realize that this particular thing is no longer a threat. Many perceived threats have been carried into adulthood from childhood, but adults are often no longer afraid of the things that scared them as a child.

Counselors can ask clients, “How do you know when you are angry?” or “What would I see in you if you were to get angry?” I often ask clients how often they get angry, how long it lasts and what patterns they have noticed with their anger. The goal is to get them to self-evaluate and search for the sensations and movements that accompany the anger. It can also be helpful to have clients rank the intensity of their anger on a scale from 1 to 10, with 1 being not angry and 10 being very angry. Counselors could ask, for example, “At what number would you say you lose control?” This exercise prompts further self-evaluation, provides a feedback mechanism and delivers an opportunity to establish a window of tolerance.

In addition, counselor must consider the diagnosis and presentation of the anger. For example, anger resulting from posttraumatic stress disorder could require a different approach than anger stemming from a relationship conflict or a social injustice.

Creating a sense of safety

I believe that the establishment of safety — real physical, emotional and spiritual safety — is the primary task of counselors working with clients who are angry. When anger is protective, we cannot expect people to remove their armor if the arrows are still flying. People are often living in chronically unsafe situations, and they do not always feel safe enough to let go of their protective anger. It is important to note that we cannot always help clients achieve full safety in their homes or work; people live in an endless variety of complicated situations, most of which are beyond our reach in the hour we get with the client each week.

So what kind of safety can we reliably provide? We can certainly ensure the safety of the therapeutic space itself, in both the physical and virtual spaces in which we meet with them. The therapeutic alliance also plays a central role in creating a sense of safety. If we can achieve even an hour of physical, emotional and spiritual safety, then we have done a great service in helping clients work on the anger issue. It’s difficult to feel angry when we feel safe, and this calm state also makes it easier to access underlying factors of the anger.

I am a huge proponent of facilitating calming and relaxation exercises for clients struggling with anger. I use these exercises in nearly every session, including the initial ones. Early on, I like to incorporate deep breathing or box breathing, mindfulness and/or meditation, depending on the client. The goal is to try to reduce the intensity of the anger, and clients often respond well to repeated, focused attempts to calm themselves down. Focused breathing gives us an immediate and familiar task that not only provides our bodies with plenty of oxygen but also helps stimulate the parasympathetic nervous system, which reduces anxiety and slows our heart rate. As the mind and the body start to calm down, and our attention is diverted from our thoughts to our direct sensory experience, our awareness rises. Tuning into our senses is our best shot at perceiving and responding to our actual reality, at least what we perceive as a reality. This is a great position from which to assess and make good decisions.

Counselors cannot control the external factors in the clients’ lives, but we can demonstrate to them that with practice, they can gain control of their responses. Since anger is often about protecting oneself or about summoning a great amount of energy and determination all at once, we want them to have a distinct feeling of what it is to be calm and relaxed as a counterbalance to that anger. Some clients are not used to feeling this sense of calm or they do not experience it often, so it can be helpful to have them practice entering this calm state during session. Counselors can help them become familiar with what their resting heart and breathing rates feel like. The more time clients spend in that safe, calm state, the easier it will be for them to return to it when they feel themselves becoming angry. This knowledge allows them to be proactive in their response to those changes.

Regaining control

Counselors should encourage clients to express their anger in safe and healthy ways within the therapeutic space. Learning about what makes them angry provides counselors with an opportunity to normalize and validate it. Counselors can also teach clients alternative ways to express their anger without the typical behavior of yelling or hitting, for instance. Counseling provides them with a space to talk about their anger and give voice to their experience. They get to feel the anger but this time without any negative consequences or judgment.

Some clients feel relief simply by expressing their anger. Allowing clients to explore their anger in this way helps them gradually untangle it from danger or their past experiences a little bit more. Counselors can also help clients discern when there is an active threat that warrants anger. This can help them realize that being angry at common annoyances, such as when someone cuts them off in traffic or when a co-worker doesn’t return their email, may not be worth it. There is no strategic or adaptive advantage to becoming angered by those situations. In fact, there is a decisive disadvantage because for many people, anger reduces functioning in daily life.

People who are overwhelmed by their own anger often experience unintended negative consequences in their relationships and careers. They know better than most that there is a heavy burden and cost associated with this anger.

It is also important for counselors to help clients understand that anger itself is not a bad thing and there are safe, nonharmful ways to express their anger. Feeling freer to explore their anger enables them to safely address it more often in their lives, which results in fewer negative consequences. Eventually, this feedback loop creates its own momentum. They will want to practice the calming skills the more they see the tangible benefits of the methods. This means counselors can’t let them slack off in this regard. Probably the time I am most directive in session is when I am trying to get clients with anger management issues to practice mindfulness and relaxation exercises. I usually tell them that if they are resistant to taking three deep breaths a few times throughout the day, then they owe themselves five. When a client is resistant to doing even basic anger management work, even though they have come in for that, I become more interested in the secondary gains they get from being angry, which can be difficult to identify but they will be there.

Clients also benefit from functional alternatives to being overwhelmed by anger. Now instead of “flying into a rage,” the client is beginning to take some deep breaths, listening to their own heartbeat, assessing the level and intensity of their anger, reviewing their own expectations and beliefs about the encounter, and determining if it’s a threat in the present moment or if they are responding to something from the past. These techniques help slow them down, engage their prefrontal cortex, and give them something positive and constructive to focus on instead of simply allowing them to be flooded and overwhelmed by their anger.

Mastering the moment

When we believe that we or others are being wronged in small or large ways, our anger can be incredibly effective at giving us the energy to make a change. A client who is angry about a social justice issue may not need to “manage” the anger as much as channel it. Understanding the context of the anger as clients see it will greatly inform counselors’ course of action in session.

And we can also decide how upset we want to be when our friends, families, and co-workers offend or anger us. We can use the energy to do whatever is necessary, which may include reasserting boundaries. We can also choose sometimes to let it go because we know that we have wronged people as well and we all make mistakes. That is a learned skill — one that requires empathy and a desire to understand another person’s context before rushing to judgment. We don’t have to be swept away by the other myriad interpersonal situations we encounter that can cause our anger to arise.

Sometimes helping clients regain control of their anger boils down to helping them master a small but very difficult moment. Some of our worst impulses in moments of anger last for mere seconds before they pass. To act on them may be to court calamity, and so to not act on them is a very great power. There are lots of people who will have a much higher quality of life if we help them pause and process the situation before determining if and how they want to respond to their feelings of anger. For this reason, mindfulness and emotional regulation techniques from dialectical behavior therapy can be effective because they lend themselves quite naturally to this specific endeavor.

Cognitive behavior therapy has also been known to be effective in helping clients manage their anger. So much of anger starts as a cognitive process. If someone is driving and another person cuts them off, for instance, they have two choices: Get angry and yell, “Hey, that jerk cut me off!” or shrug and say, “He must be in a hurry.” These two ways of processing this situation are diametrically opposed. In the first instance, the person may become enraged and behave impulsively. In the second, this event is just an ordinary occurrence that is hardly worth mentioning.

Our self-talk makes an astonishing difference. And when the client’s defenses are down even a little, we can help them examine their thoughts and make changes where appropriate. We help them choose the self-talk that gets them the desired emotional and behavioral result they are seeking. Cognitive behavior therapy also allows the counselor and client to work backward and consider what the client needs to think or do to stay calm in situations that make them angry. In the previous example, the counselor could ask the client, “If you were to feel calm when someone cuts you off in traffic, what would you need to be thinking?

Most of the cognitive work has to come after the establishment of safety. Clients need to have a clear road map of the place they are trying to get to. They will still get angry and sometimes do impulsive things that create unpleasant consequences for themselves and others, but we can compassionately help them deconstruct the event and its precipitating factors and gently remind them there are other healthy options for expressing anger.

When safety is present, the client’s protective armor of anger can be removed. With the armor gone, we as clinicians may see the injury more clearly, and in turn, the client will be free to walk through the world less encumbered.

Peter Allen is a practicing therapist in Richmond, Virginia. Contact him at peterallenlpc@gmail.com.

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 ct.counseling.org/feedback.

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.

Advocacy Update: National strategy to address the mental health crisis

By Sydney Sinclair April 25, 2023

A woman sitting with her elbows on her knees. A man sits across from her on a couch.

Jacob Lund/Shutterstock.com

In February, President Biden delivered his annual State of the Union address, calling for bipartisan unity and emphasizing the need for Congress to work together on legislation to move America forward. Topics covered ranged from health care to economics, as the president highlighted bipartisan legislation that can unite us all.

In the speech, Biden emphasized his plan to continue to advance progress made on the Unity Agenda that he first introduced last year. The Unity Agenda is the administration’s strategy for harnessing historical bipartisan support in four policy areas: 1) combating the nation’s opioid crisis, 2) addressing the mental health crisis, 3) increasing health care access and support for U.S. veterans and 4) continuing the Cancer Moonshot initiative

Biden’s strategy to address the mental health crisis in America has the following three objectives, which are supported by the American Counseling Association’s legislative agenda.

Create healthy environments for children and adolescents. Biden highlighted the importance of protecting and fostering the mental well-being of children and adolescents. ACA is in support of programs that make students safer at schools, improve school climate and improve access to mental and behavioral health services at school. The Student Support and Academic Enrichment Grant under Title IV-A of the Every Student Succeeds Act is a flexible block that is designed to ensure that school districts provide students with a well-rounded education, use technology to improve academic achievement and digital learning, and improve conditions for student learning.
Expand access to mental health services via the Counseling Compact and the Mental Health Access Improvement Act. In his address, Biden stressed the need to make behavioral health care affordable and accessible to all Americans. Last year, the Counseling Compact met the 10-state minimum needed to trigger formal establishment for interstate license reciprocity. Portability expands access to mental health services and decreases shortages of providers in certain areas by allowing counselors to practice in other compact member states. The recent passage of the Mental Health Access Improvement Act is expected to close a widening treatment gap for Medicare beneficiaries by giving them access to more than 225,000 additional licensed mental health professionals. The Biden administration plans to allocate three times more resources to promote interstate license reciprocity for the delivery of mental health services across state lines.
Strengthen system capacity by expanding the behavioral health care workforce. For the system to withstand capacity, a focus is made on recruitment, funding and researching the behavioral health workforce. In December, Congress voted to pass the 1.7 trillion-dollar fiscal year 2023 omnibus package known as H.R. 2617, the Consolidated Appropriations Act, 2023. Among the provisions included in the omnibus was the Mental Health Access Improvement Act (S. 828/H.R. 432), which will expand access to mental health services by allowing licensed professional counselors to be reimbursed by Medicare. ACA has since been working with the Centers for Medicare & Medicaid Services and other partners to implement rollout by Jan. 1, 2024.

ACA also continues to fight for the inclusion of counselors as mental health providers in the U.S. Department of Veterans Affairs and the Commissioned Corps of the U.S. Public Health Service. This would reduce wait times for veterans seeking behavioral health services and would expand career opportunities for counselors, as intended by the administration.

If you would like to become involved in ACA’s advocacy efforts, visit the Take Action page or contact the Government Affairs and Public Policy team at advocacy@counseling.org.

Sydney Sinclair is the government affairs coordinator for the American Counseling Association. Contact her at ssinclair@counseling.org.

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.

Building rapport with clients experiencing psychosis

By Tina C. Lott April 13, 2023

a person looks off to the side with her hand over her mouth and the other by her head; another person sits across from them with a notepad

Ground Picture/Shutterstock.com

When discussing working with clients experiencing active psychosis, I once had a counseling student ask me, “Dr. Lott, what’s the point of trying to build a relationship with a client who isn’t even sure they are on the same planet as me? I mean, does it really matter at that point if I get to know them?” Taken aback, I responded, “If this client were your loved one, would you still have this question?” This exchange helped the student realize the importance of seeing clients from a place of compassion, no matter their symptoms, but it also made me wonder how often other students and counselors have pondered this same question.

In a traditional counseling session, building rapport is one of the most important tasks that the therapist will have. Rapport building helps the client feel welcomed, heard, seen and validated and helps improve the therapeutic process. In addition, research supports the notion that the counselor-client therapeutic alliance has a significant impact on treatment outcomes. Thus, regardless of the issues clients bring to session, the relationship bonding between the therapist and the client is essential.

But what about clients who are actively experiencing psychosis? Should therapists take the same time and effort to build a relationship with them? The straightforward answer is a resounding yes, but unfortunately, many clinicians do not always intentionally practice this.

Research studies indicate that counselors agree on the importance of rapport building with this population. So, if counselors know that this is important, then why do some struggle with this when it comes to working with individuals diagnosed with active psychosis? Nearly all the supervisees I have worked with have told me that they initially had a difficult time building rapport with clients experiencing psychosis. Because this process can be challenging and unique for clients with severe mental illnesses, I offer insights from my own experiences on why building rapport is important for this population and effective strategies on how to do it.

The need for rapport building

Throughout my research and work with the mental health community, I have noticed many articles implying that individuals living with severe mental illnesses are violent or dangerous and that caution should be taken when working with this group. Some articles talked about the importance of managing a hostile environment and being aware of exit doors and ways to call for help should things escalate. Although this is possible in some cases, hostility and danger have not been my experience when working with this population, and I have worked with some of the most severe forms of psychosis. In most cases, I have not felt threatened or on edge when working with this population. This sort of thinking is more prevalent due to the stigma associated with severe mental illness. I have found that people are often afraid of what they do not understand, and therefore those with severe mental illnesses are often ostracized, discriminated against and stereotyped.

During my 11 years working with clients experiencing severe mental illnesses, I have found that my rapport with clients supports them in treatment by helping them adhere to medication (when applicable and desired) and engage in services specifically designed to help reduce symptomatology. Clients who are experiencing active psychosis are likely to be skeptical of anyone outside of their world. Some symptoms, such as paranoia and severe anxiety, may have convinced them that others, especially mental health professionals, do not have their best interests in mind. Often, their reasons for suspicion and skepticism are warranted. Many clients with severe mental illnesses have had negative and often traumatic experiences with the counseling profession due to well-intentioned but poorly trained or unaware clinicians. Therefore, the odds are against us when it comes to building the therapeutic alliance.

Even though it is challenging, I’ve found that building a therapeutic alliance with this population is one of the most effective interventions counselors can implement. In addition, it can be a positive interaction that counters any potential negative mental health experiences clients have had in the past. It is safe to say that regardless of whether a client is experiencing active psychosis, having someone that they trust is always helpful when it comes to the treatment plan, emotional and psychological commitment, and their overall well-being. And for clients with severe mental illnesses, it is a necessity.

There are many benefits to creating a strong therapeutic alliance, but here are three main reasons why rapport building is important for clients with severe mental illnesses:

Trust creates relationships and relationships can lead to progress. A client’s trust in their mental health professional provides an opportunity for the client to receive care. No matter how severe one’s psychosis may present, trust is important when it comes to adherence. If a client does not trust their team, they are less likely to engage in the services offered to them. Clients need to know that mental health professionals have their best interests in mind and that the goal of counseling is to help them find relief from the symptoms that may have caused them to seek or receive treatment. Building a trusting relationship with just one mental health professional can help clients de-escalate when they are in a state of crisis, assist with medication and therapy adherence, and encourage the client to be an active change agent when addressing collaborative treatment plan goals.
A sense of connection and belonging can build community. Those with severe mental illnesses often feel alone and misunderstood, which can cause them to self-isolate. Research has shown that people diagnosed with severe mental illnesses tend to connect with others who have severe mental illnesses because they do not feel a sense of belonging with people who do not have similar diagnoses. According to Patrick Corrigan, the program director of the Honest, Open, Proud program (which aims to reduce the self-stigma associated with mental illness), one of the best ways to understand people with severe mental illnesses is by forming connections, having conversations and engaging in shared activities with them. Counselors can establish a healthy connection with this population by engaging in the client’s community as an observer, remaining curious by asking questions, dispelling biases and stereotypes, and working with the client in a benevolent and nonjudgmental way. When counselors approach clients from this perspective, clients are more willing to allow the counselor in, which helps foster an authentic relationship and a sense of community.
A strong rapport positively affects treatment outcomes. In the first edition of his book The Basics of Psychotherapy: An Introduction to Theory and Practice, Bruce Wampold said the therapeutic alliance is one of the most important aspects of the counseling process and it often leads to favorable outcomes. This continues to be true today. Wampold stressed that the stronger the alliance early on, the better the outcome. The trust developed between the counselor and the client is a sacred and unique connection that happens within the counseling session, and it creates a safe place for the client to express their inner thoughts without judgment. For some clients, it may be the first time they have experienced a healthy relationship. Individuals with severe mental illnesses have most likely felt betrayed by the mental health system and are therefore reluctant to share how they truly feel. For example, a client once told me that he did not want to share how he felt because he feared he would be hospitalized or punished. After taking the time to reassure the client that I was there to listen and support him, he started to share his true emotions. Gaining the client’s trust could help uncover many other symptoms that get in the way of the client living their optimal life. Lessening of the severity of symptoms and connecting the client to the appropriate resources, in turn, can reduce their need for mental health services and address symptoms that may have led to hospitalization in the past. In other words, the bond formed between the counselor and client has the potential to decrease the cyclical impact of overutilized mental health services because clients are listened to and validated.

Strategies for building rapport

I think that depending on the environment, the culture of the clients you are working with and the clinician’s skill set, there are many ways to connect with clients with severe mental illnesses, including those experiencing psychosis. In my extensive work with this group, I have found that the following strategies work exceptionally well.

Get on the same page as your client. The counselor and the client should always work collaboratively toward the client’s stated goals. Frequent check-ins to make sure that the goal has not changed are important when it comes to assessing progress. When counselors make goals for the client as opposed to with the client, a therapeutic disruption occurs, resulting in the client not being an informed and active change agent toward their goals.

When working with psychosis, establishing a common goal may require the counselor to be more flexible and creative in their approach. For instance, I worked with a client who heard voices and her main goal was to stop her voices from disrupting her while she studied. Of course, I could not guarantee that she would achieve this goal, but what I could do was offer ways in which the client could learn to tolerate the voices so that she could still study. So we adjusted the therapeutic goal to focus on learning coping strategies to distract her from the voices.

Counselors have the responsibility to make sure that treatment is geared toward the client’s benefit, wellness and preferences. When this alliance is in place, treatment outcomes can improve.

Stop talking and listen. One of the most effective interventions for working with any client, especially those who are experiencing psychosis, is to listen to the message that the client is trying to convey. When working with psychosis, there is some truth in even the most delusional of statements. I once worked on a psychiatric unit and had a client who believed that the devil lived in his rectum. Most of the mental health providers that he had encountered before me dismissed this statement, often attributing it to his psychosis. When I did my assessment of him, I asked more questions about this “devil.” I asked what it looked like and why it might have chosen to live in his body. Although his response was tangential and disorganized, I learned that this “devil” was really the client’s way of telling us he had been sexually abused. This “devil” was a result of trauma. It represented one of the most detrimental moments in his childhood. Had others mental health professionals listened and been more patient, it is possible that his trauma could have been addressed much sooner.

Hold back your urge to assess and evaluate. Over the years, the agenda in the counseling profession has been clear: Diagnose and then move the client through the treatment process. So it has become second nature for clinicians to walk into a session, assess a client, assign a diagnosis for billing purposes and move on to the next client.

The problem is that clients can see right through this. They can tell when there is an agenda or when they are a part of this system. Clients come to the session to feel heard and validated. They do not want to be a part of the “mental health assembly line.” Clients who have had a long history of being a part of the mental health system often feel like just a number or another item to cross off a counselor’s checklist. This has decreased their trust in the mental health profession. In addition, it has made clients not want to disclose and tell their stories because they are in the room with yet another entity who will write it all down, not thoroughly address what was shared, and then move them through therapy without ever really addressing the core issues or providing resources for dealing with what they shared.

Clients are constantly asked to be vulnerable and do not always get what they need in return. Clients with severe mental illnesses have often experienced significant trauma in their attempts to address their mental health needs, so having a counselor who is curious, welcoming and nonjudgmental can create for a strong foundation for a therapeutic alliance. Diagnosing is necessary, but it does not have to come before a therapeutic relationship is built.

Do not argue with delusions; they are a symptom of something bigger. When working with clients who experience symptoms such as delusions or hallucinations, I have seen new and even seasoned counselors get into a power struggle with clients. This never ends well, and it greatly diminishes rapport. Counselors who enter a power struggle often focus on the wrong things in session. This is especially true with clients who present with psychosis. It is human nature to debunk something that seems untrue. When aware, it is even natural to debunk things that are irrational. But this is not ideal in the beginning stages of rapport building. When working to build rapport, telling a client that their delusions and perceptions are not real is like saying you do not want to hear what they have to say. It communicates that you are another person in their life who is not listening to them.

Instead, if counselors focus on the symptoms that are getting in the way of the client’s everyday goals, they could help the client make more progress. For instance, I once worked with a client who believed that people put snakes in her soup. Because of this, the client would not make or eat any soup. Instead of confronting the client and making a case that there were no snakes in her soup, I focused on the foods that she enjoyed eating. Last time I checked, you cannot starve from not having soup as a part of your diet, so I focused my attention on the symptoms that mattered in her day to day and did not spend energy debating about delusions that had no real bearing on her well-being. I have found that when we concentrate on helping clients focus on their personal goals and everyday functioning, some of the psychotic symptoms tend to take a back seat and are less of a disturbance.

In her master’s thesis, “Best practices of building therapeutic alliances with clients living with psychotic disorders” (published by St. Catherine University in 2017), Nicole Rominski expressed similar thoughts when she stressed the importance of focusing less on diagnostic criteria and challenging delusions and more on the distress that the symptoms cause because this is the more significant issue. Doing this does not mean the symptoms go away, but they are less likely to consume the client’s attention, which would be a positive outcome for many clients with psychosis.

Ask how you can assist and do what you can to help. Our main role is to assist, advocate and support the clients that we work with. If you work with clients who are actively experiencing psychosis, you may wonder what they would need to feel supported. That’s a great question, and the client is the person best suited to answer it. Asking a client how you can be of support to them or what you can do to help them can open the doors in two ways. First, the client understands that you want to listen to them and you are there to help them. Second, it helps build trust between you and the client, especially if it is the first time a mental health professional has directly asked them this question. Even if you cannot support them in the exact way they want, you can still listen, provide resources that address their needs and show the client that they matter.

Humanize the experience and share the client’s story with the treatment team. Once you have done the important work of taking time to listen, validate, empower and advocate for your client, share what you have learned with the interdisciplinary team. You have an insider’s view of what the client is experiencing. You have deciphered the hidden messages within the delusions and gotten to the core of the message that the client is trying to share. It is important to make sure that others who will be working with this client know this information as well.

This approach also benefits the client in three ways. First, sharing the client’s story humanizes them and allows their diagnosis to take a back seat to who they are as a person. In other words, we see the person first and not just their diagnosis. This does not mean that symptoms will be ignored and unaddressed; instead, understanding the client in context is crucial to effectively treat their symptoms. Second, sharing this information also helps family, friends, mental health providers and others know how to approach the client, which in turn can help the client feel safe. And it saves the client from having to repeat their story. Third, the treatment plan will be more individualized for the client now that their symptoms can be understood and addressed in context. In turn, health professionals can better understand and target the underlying causes of distress, thereby improving the client’s mental health and well-being.

Conclusion

There are many reasons why it is important to build a trusting bond with our clients. For those with severe mental illnesses, building rapport is the most important step when it comes to seeing positive change and progress. Stigma has exacerbated some of the most harmful myths associated with clients living with severe mental illnesses and has caused significant misunderstandings related to how to establish a rapport and working relationship with them.

I am thankful to the student who bravely asked about the point of trying to build a relationship with a client in active psychosis. Not only did it help me realize how common it is for people to contemplate this question, but it also motivated me to provide some clarity and understanding regarding this population and the challenging work that comes with it. I am grateful to the hundreds of clients I have worked with that have taught me how to remain curious, compassionate and solution focused to address their needs and wants from the counseling profession.

Tina C. Lott holds a doctorate in counselor education and supervision and is a licensed clinical professional counselor, certified alcohol and other drug counselor, national certified counselor, approved clinical supervisor and board-certified telemental health provider. She serves on the board of directors for the National Board for Certified Counselors’ Center for Credentialing & Education, and she is an academic program coordinator and core faculty member at Walden University. She has a YouTube channel specific to addressing stigma and all things mental health. In addition, she is an independently contracted therapist at PATH mental health, a mother of two fantastic kids and wife to her life partner. Contact her at tina.lott@mail.waldenu.edu.

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.

Fast-food frenzy: Treating emotional eating

By Scott Gleeson April 11, 2023

A close-up of someone eating; two hands are grabbing food from a table with pastries, hamburgers, chips, and fries

Flotsam/Shutterstock.com

Emotional eating may be one of the most disguised forms of escapism clients turn to when dealing with stress or trauma. Carolyn Russo, a licensed mental health counselor (LMHC) in Seattle, says fast-food drive-thrus have become a type of coping mechanism for clients who are stressed or struggling emotionally. That’s in large part because the consumption of processed foods has become more and more normalized in U.S. culture since it was popularized in the 1950s. According to surveys published by the Centers for Disease Control and Prevention in 2018 and 2020, more than one-third of adults, children and adolescents consume fast food on a daily basis.

Emotional eating can also be a blind spot for professional counselors because it largely falls under the realm of nutrition, which is outside of a therapist’s purview. So a clinician’s instinct may be to pass off all or most eating-related emotions to a registered dietitian. However, Russo says that ethical tendency for therapists to stay in their own lane or look past a client’s eating habits can lead to a missed opportunity when assessing clinical care.

“We’re trained as clinicians to be looking at other coping mechanisms and different patterns like a client’s failed relationship after failed relationship, not a client’s relationship with food,” notes Russo, a member of the American Counseling Association. “Emotional eating can be a little sneakier and more hidden because all forms of eating are intertwined in our culture as acceptable. We eat food at social gatherings and it’s so accessible.”

Russo says she’ll always use an intake session with a client to gain a better understanding of what their relationship with food looks like. Even if emotional eating doesn’t present itself initially, she still regularly assesses clients’ relationship with food while building the therapeutic alliance with them.

“The reality of the situation is our culture revolves around food, so it may not be something clients are even able to be honest with themselves about at first,” Russo says. It’s common in American culture for people to say, “Are you happy? Let’s celebrate by going out to dinner” or “Are you sad? Have another candy bar.”

Because people’s emotions often influence their eating habits, a client’s relationship with food is not something counselors should ignore — even if their presenting concern is not related to an eating disorder, Russo continues. “For therapists, we have to identify the emotion that clients are eating or shoving down. Otherwise, we run the risk of having that coping mechanism stand in the way of processing that real emotion like sadness, loneliness, lack of acceptance [or] fear of vulnerability, these really deep and hard emotions. It can lead clients to stay [stagnant].”

The cycle of emotional eating

Natalia Buchanan, a licensed professional counselor (LPC) who runs a private practice called Emotional Eating Therapy in Austin, Texas, has been working with clients who struggle with disordered eating since 2007, and she specializes in emotional eating. She finds that clients who emotionally eat are often susceptible to a bad recipe: They don’t have the tools to cope with their feelings and their bodies naturally crave high-fat foods. That’s why drive-thrus become an offshoot form of therapy.

“Too often I see clients psychologically go into a feast-or-famine mode, where they starve themselves or don’t plan a meal, and then their body takes over at some point to where they’re not wanting an apple or a Caesar salad; their body is wanting lots of calories,” says Buchanan, an ACA member. “Then they’re in this cycle where they want it again because the receptors in their brains say, ‘Oh yeah, that felt good last time.’ But then every time we eat fast food, afterward it’s not a [lasting] rewarding feeling.”

Buchanan says she is still seeing the ripple effects of clients’ poor eating habits that are a byproduct of quarantine and isolation phases of the COVID-19 pandemic. “I think many are still feeling the fallout from” the pandemic, she says. “But the positive is that we’re becoming more aware of how prevalent it [emotional eating] is.”

Brad Novak, an LMHC in Munster, Indiana, approaches emotional eating through a lens of deep empathy because he found himself using fast food to help him cope with his pain after his divorce six years ago.

“I was emotionally eating and wasn’t fully aware,” Novak recalls. “I’d go through the drive-thru and come home and eat dinner still. I was definitely in a place where I was leveraging comfort foods to feel good when I was coming home to an empty house or to my ex-wife when things weren’t good between us. I was afraid of ending my marriage for years and McDonald’s french fries became my way of coping several times a week.”

Now, as a clinician who specializes in eating disorders and emotional eating, Novak says targeting the behavior is the first step, but fully identifying emotional eating can still be difficult because guilt and shame can often mask a client’s potential accountability.

“For me, I didn’t even know I was doing it, so I realize how difficult it can be for clients to see that they’re turning to it,” Novak says. “The first step for me was acknowledging the behavior and coming to terms with [the fact that I was] using emotional eating as a maladaptive coping mechanism.”

“Before and during eating fast food, the feeling can be euphoric or numbing but then afterward there’s a lot of guilt and shame. The original emotion gets multiplied and you’ll feel worse,” he continues. “Then, that level of shame is in secret because eating is a part of life and something we’d need to do anyway.”

Russo, the clinical training director and core faculty at the Family Institute at Northwestern University, acknowledges that once the behavior is targeted and accounted for, the shame cycle can be challenging to offset and the emotions underneath can be difficult to untangle because of the all-or-nothing thinking. In other words, a client can get stuck being aware of the behavior but unable to stop because they feel as if they’ve already failed at a certain dietary goal.

“It’s hard to get out of that [cycle]: You’re ashamed of eating; then you eat more because you’re ashamed,” Russo explains.

Russo advises clinicians to build clients toward acceptance while simultaneously supporting their goals. “That’s where the acceptance piece comes in. Knowing it’s OK to not be perfect,” she says. “It’s more about understanding the primary emotions. If shame is consuming you, we can’t target those original emotions.”

Deborah Haugh, a licensed clinical professional counselor (LCPC) in Chicago, says helping clients accept themselves in the here and now can be integral for growth. Otherwise they’ll get tripped up in associating their self-worth with attaining a goal. “Turning to food for comfort sometimes leads to a loss of control over one’s impulses and feelings of shame,” she explains. “Our society can be obsessed with control, self-improvement [and] status, and folks who are overweight are often criticized, shamed or ignored by others to [where] that message becomes internalized.”

Haugh finds that psychoeducation on both emotional eating, which she notes is an “unhealthy coping mechanism for dealing with difficult feelings,” and shame can be a meaningful intervention.

“Life can be full of struggles, losses and sometimes trauma,” Haugh says. “What’s important is how we cope and understand and move through those struggles.”

The counselor’s role

Eunice Melakayil, an LPC and the clinical director at Serenity Found Therapy in Oklahoma City, stresses the importance of clinicians collaborating with nutritional professionals to ensure the client receives adequate care in recovering from emotional eating. At the onset, she informs clients about the limitations of counseling in treating nutrition. “I define my role as a guide in providing tools for living a mindful lifestyle, especially with being intentional in what we eat and do,” Melakayil says. “This also includes providing guidance in seeking mindful ways to take care of our bodies, including seeking medical services as needed.”

Melakayil helps host and run nutrition-focused therapy groups that provide treatment for emotional eating. “We believe doing a group eating program would bring the most benefit since members will have other members to walk the journey with,” she says.

Melakayil often refers clients who need nutritional advice to training courses provided by the Am I Hungry? mindfulness eating program, which was founded by a registered dietitian. She says separating the mental health and nutritional training roles is not only ethical but also vital from a collaboration standpoint to ensure clients receive proper treatment.

Buchanan says she often sees mental health professionals struggling to decipher when to turn to a nutritional expert and refer out. “It’s important for a therapist to not offer advice where they’re not trained and to see [if] something may be out of their depth,” she stresses. “A clinician with a diet mentality and no understanding can make it worse for a client. That’s why collaboration [with dietitians] can be so important.”

The connection to childhood

Jamie Mykins, an LPC in Orlando, Florida, knows the struggle of emotional eating on a personal level. She lives with pulmonary arterial hypertension, a life-threatening illness. Several decades ago, she lost 50 pounds by making more nutritious eating choices, and she now uses her own personal growth as a way to build alliances with clients. She says her own journey with emotional eating allows her to be more empathetic when working with clients who battle poor relationships with food.

“If it’s between Sour Patch Kids and strawberries, I want the sugar dopamine effect. Emotionally, Sour Patch Kids feel like a treat, whereas strawberries in comparison can feel too healthy,” says Mykins, noting that she will share a similar sentiment in session to build rapport with clients. “It’s tricky because food is also a part of self-care for clients. So it’s important to learn how to love food in a way that feeds you physically, not just emotionally.”

Mykins often sees a direct correlation between clients’ childhoods and their unhealthy relationships with food. “If we suffered trauma as children as so many do, eating is one of the first coping mechanisms we develop,” she says. “You can’t really turn to drugs or alcohol when you’re 6 or 7 years old. So when we’re looking at emotional eating in clients, we have to recognize that chemical dependency came super early on.”

“Clients can be programmed to believe food is a reward and we can be programmed that way too,” Mykins adds. For example, she was rewarded by her mom with ice cream if she did well on her report card when she was a child.

Russo finds that viewing emotional eating through a psychodynamic perspective can help clients work through feelings of shame and lack of control because they can see the patterns in their family or upbringing that have led to them using food as a coping mechanism. “Often I’ll have clients who had caregivers who didn’t validate their emotions and they experienced a lot of neglect,” she says. “That childhood emotional neglect leaves a permanent scar on a person and then as an adult, there are active ways to fill that void. That’s why, as therapists, helping clients to be the emotional coach they didn’t have is important.”

Haugh agrees that a client’s childhood is a good area for clinicians to explore because it can outline the genesis of when food became a source of comfort or perhaps of deprival that now plays out in adulthood. “Our relationship with food is developed in childhood,” she explains. “Food may have been used to treat or reward for doing something [of value] or as a way to soothe hard feelings. It is also common for food to be a central element in celebrations like birthdays and holidays, which for some was a time when kids could get more attention and freedom.”

“And for some children, scarcity of food was associated with basic hunger, fear and anger over unmet needs,” she adds. This leads to some clients overindulging as adults to mitigate long-held feelings of fear and anxiety around lack of food growing up.

Caitlin Ziegler, an LPC in the Milwaukee area, specializes in working with clients struggling with eating disorders and disordered eating. She says identifying wounds from a client’s upbringing can help to pinpoint what’s missing and that incorporating what’s missing into treatment can provide motivation for clients to let go of the behavior.

“Emotional eating is about filling some type of void; there’s something missing for the client and eating gives them something more than getting full,” Ziegler notes. “For a majority of clients, that void started in childhood as a form of comfort they couldn’t get somewhere else. Outlining ways to heal the void is where [therapists can be] most effective.”

Effective treatment approaches

John Deku, an LCPC at Centennial Counseling Centers in St. Charles, Illinois, says exploring a client’s past can be helpful, but too much focus in that area can delay addressing the behavior head-on. Instead, he often relies on motivational interviewing, behavioral modification and acceptance and commitment strategies for treating emotional eating.

“I find addressing what is underneath the emotional eating to be a double-edged sword,” Deku says. “Clients may want to explore their past for weeks, months or even years to find what caused the emotional eating. Most of the time, clients feel some satisfaction but end up asking, ‘So what do I do about it?’” He likes to address this question as soon as the client is ready to think pragmatically about it and is willing to change their emotional eating habits.

“I think clients can get hung up on trying to make the change feel ‘right,’ rather than letting go of what hasn’t worked and finding the bravery to try new things,” Deku adds.

Novak caters the treatment approach to the individual client because everyone has their different journey toward effective change. He says he leans heavily on mindfulness approaches looped in with dialectical behavior therapy, cognitive diffusion to outline if a client’s behaviors don’t align with their values, and the interpersonal effectiveness of acceptance and commitment therapy to help clients “gain some distance from their thoughts.”

“Emotional eating can be impulsive in nature, so one thing I’ve tried with clients is giving them the tools to break from the impulse,” Novak continues. “If a client has [a] desire to eat fast food on [their] drive home out of convenience, I’ll suggest putting their wallet in the trunk. Just that extra step of pulling over and getting your wallet out helps offset that impulse.”

Novak has also put a lot of consideration into the terminology he uses with clients, and he says that he is “on the fence” about labeling emotional eating of fast food as an addiction. “I’m mindful of not introducing addiction words with clients because there isn’t enough research on it in my opinion,” he says. “But the behavior is nearly identical to addictive behavior.”

Neither is Buchanan prone to using the term “fast-food addiction” because that sounds more condemning and less like an accepting, balanced approach. “I struggle with the idea of calling it fast-food addiction,” he says. “The only other addiction you can equate it to is sex because people need to have sex, but even then it’s different than eating. If I’m [a person with alcoholism], I don’t need to have a drink to survive like I do with food. So to me it’s more about the relationship with food. If it is addictive, what makes you sober? We have to be careful not to villainize foods because that can work against improved behavior.”

It’s also important to identify that emotional eating is situated between regular eating habits and eating disorders, Buchanan notes, because that distinction outlines severity, need for collaboration and what roles clinicians can play. And if a client doesn’t have a diagnosable eating disorder, then their emotional eating may go unrecognized or be disguised, he adds.

“I cannot tell you how many people have been in therapy for five years and will say they binge Wendy’s or Sonic in the parking lot,” Buchanan notes. “They’re ashamed of it. That’s why psychoeducating can be so important because then clients will have an understanding of their behavior and come to terms with it when they’re emotionally ready.”

Deku often makes it a priority to differentiate between a diagnosable eating disorder and emotional eating to inform his treatment and collaboration approaches. “I don’t find professional collaboration as necessary with emotional eaters as I do with [clients with] eating disorders,” he says. “Eating disorders can be dangerous and historically, they’ve had some of the highest rates of mortality compared to other disorders. … I find that emotional eaters tend to know what is healthy or unhealthy but they struggle to change habits. They may feel they’re stuck in their routines and not know how to cope without food.”

Melakayil says she’s found the Am I Hungry? mindfulness eating program to be a universal resource for clients who struggle in their relationships with food. It also helps to create a clear separation between therapists’ and nutritional experts’ roles in treating emotional eating.

“The program helps in deepening one’s understanding of root problems or identifying their true need — connection, conflict resolutions, breaking habits, working through traumas, restoring or resolving relationship issues,” she says. “Meeting one’s true needs helps reduce emotional eating and promotes intentional or mindful eating over time.”

Mykins stresses the value of defining healthy eating and self-care based on what feels true to clients, not based on external influences. She says, as much as any treatment plan, therapists can play a clear role by helping clients release the notion of being perfect.

“As clinicians, we need to be able to say, ‘we’re human,’ and so are our clients,” Mykins says. “Finding that line where we know we’re going to make mistakes but also push ourselves to be the best version of ourselves is what I strive for with myself — and with my clients.”

Scott Gleeson is a licensed clinical professional counselor in the Chicago suburbs, specializing in trauma and relational dynamics. He spent over a decade writing for USA Today, where he won national writing awards from the Associated Press and NLGJA: The Association of LGBTQ Journalists. His debut contemporary novel, The Walls of Color, and its sequel, Spectrum, will hit bookshelves in 2024 and 2025, respectively.

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.