Monthly Archives: August 2023

Voice of Experience: Disorders with the potential for dangerous outcomes

By Gregory K. Moffatt August 30, 2023

A person's feet in sneakers standing on a street before the word caution written in yellow chalk

My first trip to a psychiatric hospital was in 1978. I was a first-year college student, and one of my classes toured a state-run hospital. Like my classmates, I’d seen plenty of movies about a scary “crazy” person who escaped from a hospital and terrorized the community. But I learned on that trip — and my career experience has shown it to be true — that most people in hospitals like that came in on their own accord for help.

Our guide, the director of the facility, noted that the fence around the gigantic property was not there to keep the patients in, but rather it was there to keep others out. In fact, many of the patients in that facility could have walked out the front door any time they wanted. But they didn’t want to. They wanted help.

This trip reaffirmed what I have found to be true in my work with clients throughout my career: Most people with a mental illness are not dangerous. In fact, they are often more of a danger to themselves than others. But there are a few mental illnesses that can have potentially dangerous outcomes for others.

Three disorders associated with an increased risk of violence

Research is weak regarding which mental illnesses are correlated with dangerous behaviors. I’ve researched this area for close to 40 years, and I can assure you there is no simple answer. But here are three disorders that have the potential for dangerous outcomes and always give me cause for concern.

Reactive attachment disorder. In terms of dangerousness, reactive attachment disorder is the king. This disorder, which affects children, is one of the scariest due to the developmental limitations in children in terms of coping skills and problem-solving.

I’ve seen these children cut, pinch, hit, and even kill infants and young children. I’ve seen cases in which children as young as five years old have threatened their guardians with knives. I’ve had clients under the age of seven sexually assault younger children, and I’ve seen older children with this disorder kill family pets as well as rape adult women. Children with this diagnosis need 24/7 supervision along with intensive treatment plans.

Antisocial personality disorder. Antisocial personality disorder is the adult cousin of reactive attachment disorder. Clients with this disorder can exhibit their dysfunction in several ways. One key characteristic is that people with this disorder manipulate people. They can do this in a variety of ways, some of which don’t include violence.

But clients who choose to manipulate others physically or sexually can be dangerous. They have little compunction regarding the injury they cause others. The desire to manipulate others and see pain can lead to horrifying behaviors. These patients will attack staff or fellow patients in hospital settings, and they can easily attack therapists in outpatient settings. Individuals with this disorder are often the characters many of us know of as serial killers and serial rapists. Much of what I’ve seen of these individuals over my career is not far flung from the movies.

(For more on this disorder, see my article “Counseling encounters with the puppet masters,” which was published in the February 2019 issue of Counseling Today.)

Delusional disorders. My wife and I visited a restaurant in downtown Atlanta recently. As we approached the restaurant, I saw a man pacing back and forth on the sidewalk in front of us near the front door. He was clearly homeless and suffering from delusions. We gave a wide berth to the guy as we entered, but from our table, I could still him through the window. It grieved me to watch this gentleman outside the restaurant suffering in front of me.

As with antisocial personality disorder, individuals with delusional disorders exhibit their symptoms in a variety of ways. Only some of their expressions are dangerous. The sensory hallucinations (auditory, tactile, visual, etc.) that these clients experience are absolutely real to them.

But unlike antisocial personality disorder, these individuals are not dangerous out of spite or cruelty. Instead, the delusions they experience and the chaotic worlds in which they live can cause them to feel threatened and, in response, act out. This is why I steered clear of the homeless man as I entered the restaurant.

In other cases, their delusions lead them to think they are helping when they are doing the opposite. For example, Russell Weston, a 42-year-old man with schizophrenia, killed two Capitol police officers in 1998. He believed he was saving the world from aliens and was trying to access the “ruby satellite” he believed to be housed in the U.S. Capitol.

Violence risk assessment tools

Assessing dangerousness is a complicated process and an inexact science, and this can cause some mental health professionals to worry about assessing and treating clients with these disorders. But there are clinical tools that can help clinicians better assess the risk of potential violence.

I developed the Violence Risk Assessment Checklist in the 1990s (available at gregmoffatt.com) and have used it for years in businesses. This hierarchical checklist, like a suicidal ideation checklist, helps counselors evaluate for increased or decreased risk of potential violence. It contains twenty-eight items. Of the top eight, the more items the counselor checks when assessing the client, the higher the risk of violence.

The National Institute for Occupational Safety and Health provides a list of violence risk assessment tools that have been developed specifically for determining a person’s potential for violence to themselves or others. This list includes the Dangerousness Assessment Tool, which is a quick assessment scale clinicians can use to determine if an individual who is displaying signs of potentially dangerous behavior is a risk to others.

Clinicians need to realize, however, that just like assessing for risk of suicide, these instruments are only guides for decision-making and intervention, not precision tools.

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Next month, I’ll address who isn’t dangerous and how I know.

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.

Behind the Book: Q&A with Danica G. Hays

August 24, 2023

ACA recently released the seventh edition of the best-selling book Assessment in Counseling: Procedures and Practices. This revised edition includes new and expanded content on assessment and qualitative and quantitative approaches that can be used in face-to-face and telehealth counseling settings. Counseling Today spoke to Danica G. Hays, a professor of counselor education and educational psychology and the dean of the College of Education at the University of Nevada, Las Vegas, about what inspired her to write the new edition and how the proper assessment of clients can help build the therapeutic alliance.

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What is assessment in counseling?

In our profession, the term assessment is often erroneously used interchangeably with the term testing. When I began training and then working as a professional counselor, I learned quickly that assessment is so much more than testing. It is all the procedures and practices that occur informally and formally as the counselor and client engage in counseling. In addition, assessment is a tool for relationship building that can happen with both the client and their community. Essentially, assessment is counseling practice.

What prompted you to revise this book now and how does it differ from previous editions?

Danica G. Hays, author of Assessment in Counseling (seventh edition)

I am excited to have the seventh edition available to emerging and seasoned counselors. In general, this text has been a part of my life since I trained as a professional counselor and taught an assessment course early in my career, using the third and fourth editions of the text, respectively, co-authored by Albert B. Hood and Richard W. Johnson. Hood and Johnson were instrumental to my own learning and teaching. They provided such a strong foundation for the text, and I remain humble to be able to author and revise the text’s fifth, sixth, and now seventh editions.

The seventh edition emphasizes that assessment procedures and practices are integral components of counseling throughout the counseling relationship and that they can be culturally responsive to support client and community well-being. In addition, counselors will learn how qualitative and quantitative approaches can be used across in-person and telehealth counseling settings.

What are the benefits of engaging clients in the assessment process?

Because the assessment process is counseling practice, it is embedded in the work we do every day with our clients and communities. Thus, we engage in assessment procedures and practices in our work whether we recognize it or not. With this awareness, counselors can increase their knowledge of available assessment approaches and be intentional with their use throughout the counseling process to address presenting concerns and support overall wellness.

Assessment procedures and practices have several benefits. As a process within a counseling session, effective assessment processes can foster client self-awareness of both their challenges and their strengths and areas of resilience. They can facilitate the counseling relationship, which in turn can yield optimal outcomes for the client, such as wellness and self-empowerment. Furthermore, they can help to identify new ways of understanding mental health, resilience and social justice concerns experienced by culturally and linguistically diverse clients and communities.

Assessment processes can also extend outside of the traditional counseling session. For example, when counselors use assessment approaches such as community asset mapping or other social justice-oriented approaches, they better understand how communities can be assets for client well-being as well as their own professional and personal growth. Finally, knowledge gained from the assessment process can help inform counselors’ work with community stakeholders, other practitioners and policymakers, which ultimately advances counseling practice and our profession in general.

How has telehealth affected the way counselors assess clients?

A silver lining of the COVID-19 pandemic has been the increased use of telehealth, which allowed for cost-effective and accessible assessment processes to persist during social distancing. Before the pandemic, however, telehealth was an invaluable resource to reach clients who are traditionally underserved, such as those in rural settings, those with disabilities and those of other marginalized statuses.

Counselors who deliver telehealth assessment and counseling have a wide array of technologies available to them: telephone or video calls to provide services synchronously, wearable devices, text-based mobile health interventions, chatbots and e-consultations to support clients asynchronously. These technologies can increase access to the assessment process, but counselors also need to be sensitive to the fact that some clients may not be able to use telehealth because of a lack of access to technology or a general digital divide.

How does implicit bias affect mental health assessments?

We all have implicit bias — the attitudes and stereotypes we hold about ourselves and others — and it affects our personal and professional interactions every day. Implicit bias can be positive or negative and is based on our own cultural experiences. It can lead to discrimination or harmful behaviors based on negative attitudes held about a cultural group. Racism, sexism and other forms of discrimination (e.g., heterosexism, classism) occur in assessment when counselors use cultural group membership as the explanation for assessment findings. In other words, the counselor says that race or other cultural markers cause systemic differences, alluding to minority group membership as deficient in some manner.

The impact of implicit bias — through acts of discrimination — has sustaining effects that extend beyond an assessment finding. For example, research in school settings demonstrate that implicit bias can impact student learning, lead to improper placement in special education, yield harsher disciplinary actions (e.g., suspensions, expulsions), and cause general “adultification” of children that leads to insufficient support of their developmental, psychosocial and academic needs. In clinical settings, implicit bias has been connected to misdiagnosis, improper intervention use, inaccurate prognosis and underutilization of counseling services.

Thus, implicit bias can easily enter our work as counselors, affecting how we assess and intervene with clients, which has short- and long-term effects on clients’ psychological, social, academic and career outcomes, to name a few.

I challenge emerging and seasoned counselors to reflect on their initial impressions of a client and where those impressions may originate. In addition, I encourage them to constantly seek information that may disconfirm those initial impressions. Professional development through ACA and consulting with peers invested in multicultural and social justice competency are invaluable supports for continued professional growth for addressing implicit bias.

What advice would you give to new counselors who may have doubts about their ability to accurately assess clients?

Assessment can be a scary verb! I encourage counselors to remember that assessment has several flexible procedures and practices that can include qualitative or quantitative features. Every counselor, whether emerging or seasoned, can learn new strategies for engaging in effective assessment.

Being able to effectively assess clients is part of your journey as a developing counselor. We are trained to be engaged with clients through foundational helping skills, such as active listening, conveying authenticity, unconditional positive regard and empathy. I recommend that counselors rely on these skills to develop a therapeutic alliance with clients. As the alliance is strengthened, the likelihood that clients will disclose clinically relevant information and gain self-awareness of their presenting concerns and strengths can advance the assessment process. In turn, the assessment process can strengthen the therapeutic alliance, but without establishing an initial counseling relationship, effective assessment cannot occur.

Throughout the book, I provide several tip sheets to support counselors as they consider a variety of assessment approaches as well as strategies to effectively implement those approaches. The book begins with foundational information about assessment and the initial counseling and assessment phase and then transitions to crisis and trauma assessment and assessment procedures and practices for more focused mental health, addictions, cognitive, academic, career, personality and interpersonal concerns.

How can counselors communicate clinical assessment results with clients?

Although communicating assessment findings is usually considered the last phase of the assessment process, effective communication starts at the beginning of counseling. I recommend that counselors discuss with their clients why various assessment approaches are selected, what uses the various approaches have, what their strengths and limitations are, what clients can expect in terms of how these approaches will be introduced and administered during counseling, and how various findings and scores are interpreted and what potential implications those have for the client. If counselors have done a good job of navigating their clients through these assessment process steps, communicating assessment findings will have a greater benefit to their clients.

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Order Assessment in Counseling: Procedures and Practices (seventh edition) from the ACA Store.

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.

Cultivating patience in counselors

By Joanna Mercuri August 22, 2023

A woman stretched out on a sofa with a therapist; the woman is smiling

wavebreakmedia/Shutterstock.com

Maia moved to New York City during college to pursue her dream of working in journalism. At 24, she had already found success in her nascent career, landing a coveted internship and then a job at a major news network. She was bright, introspective and candid, and she was my second client ever. (Maia’s name and identifying details have been changed to protect confidentiality.)

Maia sought counseling for bulimia, which she developed as a teenager, at the training institute where I was a counseling intern. Her eating disorder had waxed and waned over the years, but it had become significantly worse three years earlier in the context of an abusive relationship. Although this relationship had ended, the trauma continued to haunt her. When she started counseling, she was motivated to put bulimia behind her; she had already gone 30 days without bingeing or purging. She also wanted to stop drinking because it often triggered bulimic behaviors. But most of all, Maia wanted to reclaim her sense of self after being with a man she said “broke her mind.”

At first, Maia’s candidness came as a relief. As a novice counselor, I was still apprehensive about silence in the therapy room; I feared it would appear as if I didn’t know what to ask or do next, which in fact was usually the truth. My supervisor often urged me to practice patience with my clients. She noted I tended to fill silences with concrete coping skills (e.g., “Have you tried deep breathing?” “Do you know the 5-4-3-2-1 technique?” “Let’s talk about distress tolerance.”) or multiple-choice questions about what a client might be feeling, rather than asking short, open-ended questions that encouraged them to unearth their own insights.

“Don’t rush in and try to fix things,” my supervisor advised. “Listen and try to understand.”

Don’t rush to fix

My first session with Maia went well — perhaps too well. She was forthcoming about her bulimia, alcohol use and trauma, but then she canceled her appointment the following week. I wondered if we had approached too much too soon. Over time, this scenario became a pattern for us. Maia would come to a session, speak honestly and openly about all that she had been feeling and reflecting on during the week — practically purging her feelings in the room — only to cancel her next session as well as any makeup session we attempted to schedule. Her cancellations were so frustratingly consistent that it was a happy surprise when she did come to a session.

On the evening of our fourth session — which by then was supposed to have been our seventh — I planned to broach the topic of her cancellations. I intended to explore them in a way that I hoped would elicit any apprehension or ambivalence about therapy without shaming her for the frequent absences. She already carried plenty of shame without adding therapy itself to that burden. When she sat down, however, she was visibly upset. Over the weekend, she had gone to a bar with her co-workers and drank until she almost blacked out. She regretted breaking her promise to herself to stay sober, and in her disinhibited state, Maia confessed romantic feelings to a female co-worker. When Maia disclosed this part of the story, she began to sob. For years she had been questioning her sexuality but never revealed this to anyone. She had been terrified to acknowledge this piece of herself. What would it mean for her going forward? What would her religiously conservative Midwestern parents think?

In the span of 45 minutes, Maia revealed one of the most hidden pieces of herself, leading us to have an open and honest conversation about her sexual identity. At the end of our session, she agreed to attend an Alcoholics Anonymous meeting and was excited to continue this conversation. I asked what we could do to help ensure she kept coming to therapy. She assured me that she would make therapy a priority because she realized how much relief it brought her and how much she needed to talk about these things.

When she walked out the door and I sat down to write my notes, I was full of energy. Although I was pained by the distress this secret caused her, I was also humbled that this young woman felt safe enough to confide in me. This session with Maia gave me the sense that we were on the precipice of something important. I thought, “She is intelligent, motivated and dynamic, and she is willing to take concrete steps to achieve her goals. Maybe I will witness the beginning of real change in this person.”

But an hour before our next session, I received a familiar call. Maia wasn’t going to make it. We rescheduled for later in the week, but she canceled that session as well. I was deflated. Had the revelation been too much? Should I have seen this coming? Could I have done something more to mitigate the aftermath of such a session?

Two weeks later, Maia made it to another session and confirmed some of my suspicions. The session had been too much for her, and she had become depressed and overwhelmed and didn’t feel like coming to therapy. She admitted that she usually dives into problems — as she had done in previous sessions — but revealing her queerness had not had the same effect. She told me she needed to proceed more slowly and create a safe space for herself. My heart sank when I realized that this was precisely what we had neglected to do in therapy. From the start, Maia shared her most searing vulnerabilities in sessions. And eager to help, I let her.

In this moment, I recalled how one of my graduate professors had compared therapists to a mountain guide. We can steer clients toward more gently sloping paths and offer reasonable expectations about what may be approaching. We can even remind them to stop and take a breath. Although we cannot make the climb less difficult, we can help grant safe passage. If I was going to help Maia make the long trek toward recovery, we were going to have to put some guardrails in place. Otherwise, therapy would leave Maia feeling as painfully exposed as all her other attempted coping mechanisms.

Unfortunately, I did not get the chance to acknowledge my mistake and repair the therapeutic relationship with Maia. After one more no-show, she wrote to say that she was grateful for the opportunity to begin thinking about these issues, but she had too much going on at work to commit to therapy.

Growth takes time

Both new and seasoned counselors know the discomfort of sitting with a client’s pain while feeling powerless to intervene. My own feelings of incompetence as a new counselor will often creep in, compounding the problem. At 30 years old, I have accumulated multiple rounds of professional and educational beginnings: acclimating to life away from home as an undergraduate, starting my first “real” job as a reporter in Scranton and working in a public relations office where I pretended I knew what my editor was talking about when he asked me to do a “prewrite.”

Now, here I am again, starting over in a new career as a counselor. I feel the anxiety and confusion that often comes when starting a new position and learning new skills. But unlike previous jobs, I do not get to endure these growing pains from the privacy of a cubicle; my supervisors, instructors and clients all witness my naivete.

In Learning From Experience: A Guidebook for Clinicians, Marilyn Charles explains how anxiety compels us to tether ourselves to something familiar and knowable, such as behavioral techniques, coping skills or clever interpretations. These impulses, while often well-intentioned, can be unhelpful to clients. “Our need to find anchors — and signposts to guide our way — can make us jump too quickly on ‘meanings’ as saturated elements that leave little room for growth,” she writes.

It is tempting to forge connections and meanings for clients to provide immediate relief and illustrate our empathy and understanding. But if we truly want to help our clients, we must first be fully present so that we can develop an understanding of their world as they experience it.

I have learned alongside my clients that deep, intrapersonal change cannot be rushed. Change can be frightening, even when we are the ones initiating it. We are leaving behind the familiar with no guarantee that we will arrive somewhere better. Maia did not know — could not know — whether processing her trauma or reckoning with her sexual identity would bring her more solace than what bulimia and alcohol offered, albeit temporarily. Likewise, I have no idea whether enduring the growing pains of becoming a therapist will ultimately bring personal meaning and professional satisfaction. What is familiar may be unfulfilling or outright painful, but at least we know what we are getting.

Working with Maia showed me that what matters is building safety into the change process. We can help clients become familiar with signs of distress and overwhelm in their body and learn to view these signs as an invitation to slow down or pause and return to a calmer, more regulated state. I also learned the value of being patient. Both counselors and clients need to allow themselves time to adjust to new surroundings or situations. With each small adjustment, we gain confidence in our ability to cope, which in turn gives us the courage to press on.

I no longer rush to fill silences when working with clients. I have learned to slow down, and I teach my clients the therapeutic value of being patient with themselves and counseling. I continue to learn, along with my clients, how to become mindful of distress and overwhelm, give myself permission to slow down or take a break and, most of all, manage expectations about the meandering and often lengthy nature of deep change.

Growth takes time, no matter how much we want it to happen. Trusting that what we are doing now will pay off in the future can be difficult. The best thing we can do is cultivate patience with ourselves and remember, “Don’t rush in and fix. Listen and try to understand.”

Joanna Mercuri is a license-eligible professional counselor in northeast Pennsylvania who specializes in eating disorders and the intersection of religion and spirituality and mental health. She holds a master’s degree in pastoral mental health counseling from Fordham University and a certificate in the integrated treatment of eating disorders from the Center for the Study of Anorexia and Bulimia in New York. Contact her at joanna.mercuri@gmail.com.

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.

Making schools more inclusive for LGBTQ+ students

By Stephanie Opiela August 15, 2023

child in denim t-shirt with rainbow symbol, wearing an orange backpack outdoor, standing outside

yurakrasil/Shutterstock.com

In working with children and families who have experienced trauma, I have accompanied a diverse range of LGBTQ+ clients on their healing journeys. Sometimes their challenges arise from a single significant event, and other times, a collection of circumstances and support system failures contribute to their struggle.

When a person mentions a “support system,” the first thing that often comes to mind is one’s family or peer network. However, support systems can also include organizations, and when it comes to children, especially those in the LGBTQ+ community, schools can serve as additional and vital systems of support.

It is a well-supported fact in mental health research that LGBTQ+ individuals are at greater risk for mental health challenges than those from other groups. According to the National Alliance on Mental Illness, those who identify as LGBTQ+ are nearly three times more likely to develop a mental health disorder such as depression or anxiety and are significantly more likely to attempt suicide and abuse substances. The risks are especially high for adolescents and young adults, with LGBTQ+ youth ages 10–24 being four times more likely than their peers to attempt suicide.

Because many students in districts across the nation are part of the LGBTQ+ community and use mental health services, schools can play an important role in creating an inclusive and trauma-informed environment to prioritize mental health prevention and intervention. In this article, I share one student’s story and offer advice on how counselors and schools can create a supportive environment for all students.

One student’s experience as an LGBTQ+ individual

CJ (a pseudonym) is a high school senior who began receiving mental health services primarily to address ongoing challenges with anxiety and depression. CJ acknowledged that while a lot of progress has been made when it comes to creating a sense of inclusivity for LGBTQ+ people in their current community, they “have never truly felt included.”

Although CJ is comfortable and confident in their gender and sexual identity, they expressed that their emotional safety is challenged on a daily basis living as an LGBTQ+ individual. CJ described the deep hurt that accompanies the perpetuation of stereotypes, saying, “There is this constant stream of negative feedback on who I am as a person.”

CJ found it particularly hard to trust anyone. CJ believed that some teachers and students will “treat them as a completely different person” after learning CJ is an LGBTQ+ individual, despite having previously welcomed them into their social and physical spaces.

CJ further described the unmistakable discomfort that others display when they are outed in conversations: “There is always that pause — that deafening pause. Conversations shut down when they learn that about me. They try to escape it as quickly as possible.”

Inevitably, anger, confusion, a sense of shame and feelings of rejection accompany these all-too-frequent interactions with peers and adults. CJ explained that other LGBTQ+ students on campus tend to “stick together” for social and emotional support, but this does not diminish the challenges that accompany identifying as an LGBTQ+ person. CJ described the mental energy they must spend distinguishing safe people and spaces at school, and the crushing disappointment and loss that come with learning that someone is nonaffirming. “I wish everyone here was super welcoming, but that is too much to expect. There are people here that want nothing to do with someone like me, and it hurts,” CJ said.

CJ shared that when they came out to their family, they felt a renewed sense of freedom and happiness, but they quickly realized that sense of freedom did not translate to their school and community environments. CJ’s confidence and comfort began to crumble as they consistently found that they could not out themself unless they had determined a person or group was safe, which proved difficult to do.

Constant disappointment can take a toll on even the most resilient of individuals. “I’ve told many people in your line of work [mental health] that I’ve become less and less comfortable telling people that I am gay,” said CJ. “I’ve even gone out of my way to try and make people more comfortable by avoiding that topic.”

This transition — from being open and free to being guarded and cautious — was a significant loss that CJ continues to grieve, all while carrying the burden of other people’s discomfort with who they are. Like many others who belong to the LGBTQ+ community, CJ knew from early on that they were “different” from many of their peers. Their identity was not something that they “chose or created” but just who they were.

CJ shared one instance when their class engaged in a discussion about whether people were “born gay.” The consensus among the teacher and most students was that this was not possible but rather that homosexuality was something people chose. CJ described feeling outnumbered, unsafe and angry that a group with an entirely different set of beliefs and experiences was explaining CJ’s identity as a choice, without having any degree of understanding of who CJ was, what their life experience had been or the hurt that the conversation was causing them in that moment.

Just as many individuals who struggle with anxiety are constantly operating on high alert, many who identify as LGBTQ+ must scan for indicators of safety and inclusion, and negative experiences further reinforce a lack of trust in others and a decreased sense of safety. For this to be happening at school — where students spend most of their daily lives with the expectations of safety and support — has concerning implications. This becomes even more serious when one considers students who already struggle with anxiety and depression because of other factors.

Despite continuing support from mental health and medical professionals, CJ struggled with ongoing invalidation and oppression, and at more than one point, this bright, funny and engaging student was hospitalized because they had become suicidal. While psychiatric hospitals are a crucial part of mental health care system, they are not usually the warm, supportive and healing environments that we would like to believe they are. On multiple occasions, CJ spent days away from loved ones, with no contact with the outside world and surrounded by other patients who carried their own horrific traumatic experiences.

This is the cycle that many of our most vulnerable students endure when they do not have safe, supportive and affirming environments to be who they are while they spend their mental and emotional energy connecting with others, tackling academic demands and navigating the stress of adolescence. They survive until the weight of all their turmoil becomes too much and they fall apart. Most of the time, counselors are fortunate enough to pull them back to safety, but sometimes, these students slip away.

Steps to creating an inclusive environment

Providing and promoting an inclusive, welcoming and trauma-informed school environment is more critical than ever for ensuring that all students, including LGBTQ+ students, can experience the sense of safety and belonging that they deserve. How can this be accomplished?

Create a culture shift. School staff must first be willing to take responsibility for all students in the school. This necessitates learning from one another through communication, collaboration and professional development opportunities. Great strides have been made through the use of multitiered systems of support teams, in which staff from various departments and specialties come together to develop appropriate interventions for students who exhibit academic, behavioral or mental health needs.
Become trauma informed. Establishing a safe and inclusive school setting requires that staff be trauma informed. Staff must be willing to recognize their own implicit biases and understand that everyone has their own story. All staff — not just teachers and administrators — need to be educated and equipped to recognize basic signs and symptoms of mental health challenges and know who to contact if they have concerns about a student’s well-being.
Provide resources. Students and families need to be aware of the resources available to them on and off campus. All staff should be familiar with key resources, including local mental health authorities, LGBTQ+ organizations, crisis hotlines and bilingual providers. In addition, posters with inclusive language celebrating diversity and addressing the stigmas surrounding mental health challenges need to be visible throughout campuses.
Make time for connection. Staff should make an effort to learn the names of all their students and use their correct names and pronouns. This will allow each student to feel valued. It also models respect and acceptance for all students. To create or strengthen students’ support systems, staff should also establish regular contact with families to develop trust and build a successful partnership.

Inclusivity and equality are not new concepts, but there is still much work to be done. Our work as counselors matters because our students matter. My hope in sharing CJ’s story is for school counselors, administrators and staff to recognize the potential impact they can have in the lives of all students by being an advocate and resource on campuses and in their communities.

Stephanie Opiela is a licensed professional counselor-supervisor with over 14 years of experience serving clients with histories of adversity. Most of her career has been dedicated to serving children and families affected by abuse, first in a therapist role and then as a program director and clinical director for local children’s advocacy centers. Her work with medical professionals, law enforcement, child and family protective services, and district attorney’s offices continues to fuel her passion for promoting trauma-informed care in systems that are designed to protect children. She currently serves as a school-based therapist for a campus of 2,500 students. Contact her at stephanie.opiela@dsisdtx.us.

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

A mental wellness program for law enforcement

By Margaret Taylor August 14, 2023

Fractal Pictures/Shutterstock.com

For more than 16 years, I have had the privilege of working closely with law enforcement. I spent the first nine years of my career as a mental health counselor working alongside law enforcement in the investigation process as a forensic interviewer and counselor for victims of abuse. This relationship allowed me to better understand the unique culture and needs of law enforcement, and I realized officers had unmet mental health concerns.

After leaving that position, I opened a private practice, where I had the opportunity to develop a relationship with Jay Turner, the chief of police for Alexander City, Alabama. As a mental health advocate, he also saw the growing need for mental wellness in his department. To address this need, I collaborated with Turner and developed a mental wellness program for law enforcement. I have implemented this program in three different police departments, and it has been successful in helping improve the mental wellness of law enforcement officers. In this article, I discuss the components of this mental wellness program and share my experience using it.

Barriers to seeking help

Several barriers prevent law enforcement officers from seeking help for mental health concerns. In a study published in JAMA Network Open in 2020, Katelyn Jetelina and colleagues found that officers did not pursue mental health treatment for four reasons:

They did not know they were experiencing a mental health issue.
They were concerned about confidentiality.
They feared being misunderstood by the counselor.
They worried they would be found unfit for duty because of the stigma around mental health.

Silence in police departments also serves as a significant barrier to officers seeking mental health treatment. In a USA Today article on the Capitol riots published in 2021, Nicholas Wu and Courtney Subramanian discussed how the culture of silence at some police organizations minimizes the experiences of trauma and stress related to the job. Officers are trained to be in control of everything around them, so if they feel they are not in control, they become confused and unsure how to cope. When this happens, they often remain silent rather than ask for help. This mentality contributes to isolation, relationship problems and ultimately the perpetuation of mental health issues.

Counselors working with law enforcement can ensure they are taking steps to remove these barriers by adopting a mental health program designed for law enforcement. This program policy should stress the importance of confidentiality and assure clients that privacy will only be breached when an officer is found to be a danger to oneself or others. Officers and counselors can emphasize that the wellness program is not a fitness-for-duty examination. In my experience, approaching this immediately often leads to the officer relaxing and trusting the process more.

Police departments should also seek a counselor who is sensitive and educated on the culture of law enforcement, which will decrease the likelihood that officers feel misunderstood or judged. It is also crucial counselors encourage law enforcement leadership to promote mental wellness in their departments and reduce the stigma that prevents officers from seeking assistance.

Components of the mental wellness program

Officer wellness should be a priority for every police department, so they can better protect their officers and community members. Counselors can work with police organizations to develop a mental wellness program that contains the following four components, which I have found to be effective in my own work: a formal mental health policy, supportive department leadership, trained and culturally aware mental health professionals and a mental wellness framework.

Create a mental health policy. The Law Enforcement Mental Health and Wellness Act of 2017 calls on federal and local law enforcement departments to adopt mental health practices, including regular mental health checks. Central to a mental wellness program is the development of a formal departmental policy. Captain Brian Nanavaty with the Indianapolis Metropolitan Police Department reported in a 2015 article in the FBI Law Enforcement Bulletin that mental health counselors and law enforcement must work together to create organizational policy on mental health for it to be effective. Agencies can dispel fears of repercussions for seeking mental health by creating a policy that requires or mandates mental health treatment for all officers, not just those who have experienced traumatic incidents. I have found that requiring all officers to attend one therapy session a year decreases mental health stigma within the department and increases the likelihood that officers will seek help on their own.

After five years of using this program in three local police departments, I have found that stigma has decreased significantly, and individuals now talk openly and without shame about making counseling appointments. In addition, those in leadership such as sergeants and lieutenants now recommend officers attend counseling when they openly discuss their struggles.

Work with administrative leadership. For a mental health program to be successful, the leadership in the police department must be supportive and educated about mental health. In a 2016 article published in Police 1, Alethea Olson and Mike Wasilewski modified the National Alliance on Mental Illness’ nine suggested ways to fight mental health stigma to meet the needs of law enforcement. I have found the following three suggestions from that list are crucial for law enforcement leadership to follow:

- Leadership speaks openly about mental health. When leaders promote mental wellness, officers feel safer to seek mental health assistance.
- Leadership educates themselves on mental health. Counselors can provide evidence-based research on the benefits of mental health to leadership so they can help educate their officers about the benefits.
- Leadership displays empathy for those struggling with a mental illness. The police department should align themselves with a counselor in the community who is trained to work with law enforcement. Then, leadership can refer individual officers to this counselor when they need assistance.

I was fortunate enough to work with a police chief who followed these guidelines, but if this does not exist in your community, consider encouraging or discussing these suggestions within leadership in the police department.

Be trained to work with law enforcement. The third piece to designing a mental wellness program for law enforcement is making sure mental health professionals have been trained to work specifically with law enforcement and understand the culture within law enforcement.

Counselors must communicate that counseling is a secure place for police to talk about their experiences and express their needs. It is essential counselors do not immediately address traumatic experiences. Trauma-informed care stresses the importance of establishing coping strategies before processing trauma. For the safety of the officer, you must assess current adaptive and maladaptive coping strategies before discussing potential trauma as well as establish trust with the officer. Trust is foundational to any therapeutic relationship, but even more so with law enforcement.

I have found that during initial counseling sessions, officers may be angry for being told they must come to therapy, nervous about what to expect and hesitant to trust someone outside the police department. Thus, it is essential counselors attend to these feelings, create a safe space and make sure the officer (who is trained to be in control) still feels they have a sense of control in session. To give officers some control in session, you can tell the officer you are not going to force them to talk or stay. If they don’t want to talk, they are free to leave. You can also give them control by allowing them to choose what they want to talk about. I have found this helps ease tension and makes the client more receptive to counseling.

The success of this mental wellness program also depends on the counselor’s familiarity with the culture of law enforcement. I strongly advise counselors to develop working relationships with local law enforcement leaders, which will increase the counselors’ understanding of police culture. You can accomplish this in a variety of ways. You could schedule meetings with law enforcement leadership and ask them to tell you about policing and their department. You can also see if it’s possible to have a meet-and-greet with the officers; I found this approach helpful because officers were able to meet me before their appointment, which helped reduce their anxiety about the process. And do your own research to learn more about the culture. I have found the website police1.com to be a helpful resource to better understand the culture.

Counselors must also be prepared to handle the unique circumstances of law enforcement. This includes being comfortable with officers who may attend session in full uniform and be armed and listening to graphic details of events experienced while on duty, such as car accidents, homicides, suicides and sexual assaults. Giving the officer a safe and trauma-informed space to discuss these graphic details is important, but as the counselor, you need to be prepared to hear these details and mitigate the potential for your own vicarious trauma.

Counselors must also be able to tolerate a morbid sense of humor, which is a common coping strategy for officers during traumatic events and a way of bonding with each other while on duty. Officers are often hesitant to admit they have a morbid sense of humor for fear of being judged, so it is important counselors normalize this experience for officers and avoid passing judgment for this coping and bonding strategy.

Use a mental wellness program framework. This wellness model is a simple guiding framework that can be modified according to the counselor’s approach and the needs of the officer. Counselors can use the Indivisible Self model as a guide for the wellness program. This model includes five factors: the essential self (the spirituality of the person, their cultural identity and self-care practices), the creative self (a person’s emotions, control, humor and thought patterns), the coping self (a person’s stress management, self-worth and leisure activities), the social self (a person’s friendships and ability to love) and the physical self (a person’s exercise habits, sleep patterns and nutrition).

I often find the Indivisible Self model to be a safe and noninvasive starting point for the officer to evaluate their current wellness because the officer is in control of how much they share about themselves. Here is a process counselors can follow when using the Indivisible Self model with law enforcement:

The counselor provides psychoeducation on the Indivisible Self model.
The counselor reviews the benefits of living a healthy lifestyle.
The counselor asks the officer to evaluate each individual area of wellness within the model. This process helps the officer gain self-awareness and an awareness of both their strengths and areas of change.
The counselor helps the officer create goals for improvement in some wellness areas. The goals should be realistic for the officer and the demands of their career.
The counselor provides psychoeducation on the symptoms of posttraumatic stress disorder (PTSD) so they can recognize them in themselves or their fellow officers. Moreover, counselors should educate officers on how to practice self-care and prevent the development of PTSD, burnout and other mental health concerns.

The discussion of the Indivisible Self model, in my experience, often increases the chance that the officer wants to return to counseling. You have created a trusting relationship and given the officer control, and now they feel safe enough to make changes in their lives.

It is also important that counselors offer interventions that are practical, easily understood and approachable. Counselors who have worked with law enforcement have found mindfulness techniques, deep breathing and meditation to be effective in decreasing anxiety and stress, and ultimately increasing resilience.

In the Counseling Today article “Putting first responders’ mental health on the front lines,” Lindsey Phillips discusses how law enforcement and other first responders often find the transition from home to work challenging. I have also found this to be true in my work with law enforcement. If officers are not able to transition from work to home successfully, then they may experience relationship problems. Counselors should help officers make a plan that will help them effectively transition home.

Conclusion

Having a mental wellness program and mandating that law enforcement attend one wellness session with a mental health professional opens the door for counselors to encourage officers to be self-aware and prioritize self-care. Some officers may want to continue counseling, and then clinicians can use practices that will address the officer’s specific mental health concern. The department will not be informed if the officer returns for additional sessions, as long as they are not at risk of harming themselves or others.

To summarize, here are some things counselors need to keep in mind when implementing a mental wellness program for law enforcement:

Learn about the culture of law enforcement.
Develop relationships with leadership within the police department.
Teach administration about mental health and the benefits of mental wellness.
Work with leadership to develop a formal policy for the mental wellness program.
Take time to meet officers before implementing the program.
Do not force officers to talk or stay in their initial session.
Do not judge the officer for a morbid sense of humor.
Avoid discussing traumatic experiences in the initial session.

Traditionally, law enforcement is a helping profession, one that involves placing the needs of others above oneself. In doing so, officers often neglect their own physical, mental and emotional health. Therefore, officer wellness must be a priority for every department to protect their officers and community members. Counselors can use the steps discussed in this article to implement a mental wellness program in their community and help law enforcement begin to prioritize their mental health moving forward.

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Editor’s Note: Parts of this article were included in “Building resilience in law enforcement through a mental wellness program” published in the Journal of Police and Criminal Psychology (2022). This article has been revised to include original content for Counseling Today.

Margaret Taylor is a professor of practice and coordinator of the clinical mental health program at Auburn University. She is also a licensed professional counselor supervisor and owns a private practice in Alexander City, Alabama, where she specializes in treating first responders and trauma. Contact her at barnema@auburn.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.