Monthly Archives: September 2023

Voice of Experience: The danger of misinterpreting risk

By Gregory K. Moffatt September 28, 2023

Wooden cubes in the form of a speedometer showing the risk assessment. Hand holding pencil is pointing toward medium to high risk.

Fida Olga/Shutterstock.com

Last month I addressed the topic of dangerousness in mental health. I noted that most people with mental illness are not dangerous and that, among those who are, they are more likely to be a risk to themselves than to others. In this month’s column, I focus on who isn’t dangerous and how our fears and stigmas can sometimes cause us to mistakenly perceive someone with a mental health disorder as a threat.

Some years ago, an attorney in south Georgia called me and asked me to consider testifying in a murder case in which the attorney was counsel for the accused. The defendant had an IQ of just under 70 and he had allegedly killed his mother. The attorney wanted me to testify that the defendant’s IQ was responsible for his violent behavior.

I had to decline that request, of course. While it is true that intellectual challenges may limit one’s problem-solving skills, there isn’t any evidence that indicates intellectual limitations “cause” one to be violent.

Violence in psychiatric hospitals

In psychiatric hospitals, patients can be aggressive with each other and with staff members, but there are reasons for this other than the psychiatric disorders themselves. Although mood disorders, anxiety disorders and even personality disorders (with the exception of those I addressed last month) may be contributing factors in aggressive acts, rarely do they directly cause violent behavior

First of all, in hospitals, people with serious dysfunctions are concentrated together in a confined space. Therefore spats, disagreements and fighting are not unlikely in such environments.

Second, these patients may be withdrawing from substances, managing complicated relationship issues and managing financial burdens all in the context of their mental health issues. These added stressors on top of their diagnoses can increase the probability of aggression. It is not caused by the diagnosis itself.

Finally, some of the most aggressive individuals, as I addressed in last month’s column, can be found in hospitals, so it isn’t surprising that we see aggression in hospital settings.

Misleading data

Early research on violence and mental health was nearly all done within inpatient settings. John Monahan’s 1981 monograph was a classic example of this type of research. While it was an exceptional work, the research presented a skewed perspective on mental health in general. The findings of those early studies couldn’t reasonably be generalized to the population at large.

I aimed to address this gap in the literature by exploring violence risk assessment in the general population in my first academic article, which was published in 1991.

What we now know is that, excluding hospital practice, most of us in the mental health industry will never be assaulted by our clients, and most of our clients will never harm or attempt to harm anyone else. A widely cited study published in the American Psychological Association in 2008 indicates that 35% to 40% of psychologists are at “risk of being assaulted” by their patients. “At risk,” yes, but most of them aren’t.

In a 2011 study, the National Institutes of Health (NIH) noted that 14% of patients admitted to a psychiatric hospital had been aggressive toward other individuals in the month prior to admission. Yet again, those who are hospitalized represent a narrow segment of the overall population.

In another NIH study in 2019, researchers found that over half of the 470 clinicians in their study had been subjected to threats, verbal attacks or physical violence at some point in their career. While this is an astonishingly high percentage, we see again that “threats” are mixed in with the data of actual aggressive clients. The participants in the study reported confrontations by clients outside the office, harassing phone calls and other verbally aggressive behaviors that fell short of actual physical contact. Feeling threatened and actually being assaulted are not synonymous.

Recognizing real vs. perceived threat

I once consulted with a company that routinely hired housekeeping staff from an agency that worked with individuals on the autism spectrum as well as individuals with development disabilities. One adult male autistic worker had been working for the company for more than three years without incident even though he was on the severe end of the autism spectrum.

As we know, people with autism often don’t handle changes well. Any disruption in their routine can cause them to be agitated. In this particular incident, this worker had gone to the maintenance area as he had done hundreds of times before, but for some reason the closet where his equipment was kept was locked.

The worker became extremely agitated and was ranting in the hallway to himself, pacing back and forth. Another employee of the agency felt threatened by him, and he was eventually fired. It was a tragic end. The employee’s fear of the agitated worker is understandable, but he was no threat to the employee nor anyone else in the office.

Recognizing who is actually a threat and who is not is a critical part of our work in mental health. Individuals who are not a threat, but inaccurately deemed to be so, can lose their jobs, custody of their children and potentially their freedom, among other things. There are also dire consequences in cases where people are a threat but inaccurately deemed not to be so, including the potential loss of life.

My experience has shown me that most therapists are not well trained in distinguishing between the two. In a workshop some years ago where I presented a seminar on violence risk assessment and self-harm assessment, I asked the roomful of 100 or so clinicians how many of them worked with suicidal clients. Every hand went up. When I asked how many of them felt well trained in assessing risk, only two or three raised their hands. None of them had any significant training in their graduate programs on risk assessment.

That leaves the responsibility for learning risk assessment to the clinician. We must stay current on the research on risk assessment, and we must interpret the data cautiously.

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.

Racial bias in gifted and talented programs

By Scott Sleek September 26, 2023

Flaws in testing and racial biases among teachers and school counselors are some of the reasons many Black boys are left out of advanced learning programs and misdirected into special education, according to the article “Inequitable representation of Black boys in gifted and talented education, Advanced Placement, and special education” published in the October issue of the Journal of Multicultural Counseling and Development (JMCD). The report is part of a special issue of the journal, “Understanding the Black Male Experience: Recommendations for Clinical, Community, and School Settings,” guest edited by Isaac Burt, Erik M. Hines and James L. Moore III.

Donna Y. Ford

In the article, Donna Y. Ford, a distinguished professor of education and human ecology at Ohio State University (OSU), and her colleagues describe why teachers too rarely refer Black boys to gifted and talented education programs and too often send them to special education. Educators often develop erroneous and harmful perceptions of Black boys as lazy, unruly and apathetic, the authors note. Furthermore, tests often lack cultural context for Black students and favor those who excel at pen-and-paper exams rather than oral expression, they say.

James L. Moore III

The co-authors include Moore, distinguished professor of urban education and inaugural executive director of the Todd Anthony Bell National Resource Center on the African American Male at OSU; Tanya J. Middleton, a clinical assistant professor of counselor education at OSU; and Hines, a professor of counseling at George Mason University.

Counseling Today recently spoke with Ford and Moore about their JMCD article and the issue of racial bias in academic placement. (This interview has been edited for clarity and length.)

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**What motivated you to write this JMCD article?**

Ford: In 2023, racism is still a problem, anti-Blackness is a problem, inequity is pervasive, and underrepresentation of Black boys in gifted and talented programs is a problem. I grew up believing in the United Negro College Fund, whose mantra is: “A mind is a terrible thing to waste.” In the article, we also talk about how a mind is a terrible thing to erase. And that’s why we want more Black boys in gifted and talented education, getting the services they deserve and need.

Moore: It was an opportunity to integrate the gifted education literature with the multicultural counseling literature. These combinations are not very common in the counseling literature.

Generally speaking, Black young men and boys occupy a distinctive space in American society. Too often this group is seen as a part of a group rather than the individual. There are inescapable experiences, regardless of whether your family comes from an affluent community or from humble beginnings. You can look in any school district in America, and Black men will be grossly underrepresented in gifted and talented programs or advanced academic programs. But they will be overrepresented in special education.

a group of young children eating lunch at school, the focus is on a young Black boy

Monkey Business Images/Shutterstock.com

Ford: Black boys make up 9% of our school students, and they make up only 3.5% of students in gifted and talented education. So they are the most underrepresented of any group. We need to keep highlighting this fact, not just to teachers but to school counselors as well. When students are disengaged because they’re not challenged, then they become an underachiever, and it contributes to this overwhelming achievement gap.

What are the most critical points that you would like people to take away from the article?

Ford: We must address test bias and use alternative methods of testing, evaluating and assessing Black boys. In this article, for example, we talk about nonverbal measures and nonverbal subscales.

We must also stop placing our Black boys in special education because when you get services that you don’t need, there’s nothing special about special education. It is imperative that educators be careful and avoid racial bias when placing Black children in special education programs.

And then finally, culture matters and representation matters. We need to be culturally responsive and antiracist, and we need more minoritized professionals in our schools.

Moore: Broadly speaking, we need schools that adapt to students, rather than forcing students to adapt to schools. One of the things that we’ve written extensively about is deficit thinking and how it often becomes self-fulfilling. When a student has perceptions that the teacher doesn’t believe in their academic ability, it tends to have negative effects on their educational outcomes. It’s important that teachers communicate accurately and recognize that some communication styles convey to some students that they’re incapable.

Another issue is representation. When Black students enter gifted programs, they frequently opt out or want to get out of these advanced academic programs because there isn’t representation that is reflective of their experience or of people who look like them. In turn, they are sometimes asked to speak on subject matters that may be viewed as speaking on behalf of the group, and we know that creates anxiety, which then impacts performance.

What role do counselors play in working toward solutions for these issues?

Moore: School counselors play a critical role in students taking advanced academic courses. If the counselor only sees deficits, it will play out in how they consult and collaborate with teachers in helping students make decisions, or in how they make recommendations for the students to enter certain academic courses. So, it’s important that school counselors interrogate any deficit thinking that they may have about an individual. And sometimes the deficit thinking might be who their parents are or where they live. And we make broad assumptions. Fundamentally, I believe that great minds come from every ZIP code.

The other way counselors can help is with social, personal issues. Often, when students leave their comfort zone — and that might be friends or representation of their racial group or gender — and they enter a domain where there’s no one to draw inference from, it creates anxiety. So school counselors can help provide social emotional support. They may also need to help the student’s parents understand the significance of advanced academic curriculum and what the benefits are.

What are some problems associated with the current way we test for advanced academic programs?

Ford: Tests are biased, and in our article, we discuss two reasons for this. The first issue is the verbal loading of standardized achievement tests. The tests require an extensive vocabulary, and it does not take into consideration how Black individuals speak. We speak mainstream English, but the majority of us also speak Black English, which is a language, not a dialect.

Verbal loading means you have to have a certain vocabulary. You have to phrase things in a certain way or know certain words. And that is problematic.

The second issue is the cultural loading, which means the test items and correct responses are based on the culture of upper-income white people.

These two issues can be seen in the testing question “How are work and play alike?” We have to consider why the person writing this test chose the terms “work” and “play” and how others may interpret them. Some Black children, for example, may say, “Well, they both have four letters.” Although that’s true, they would get zero points. Instead, they may be expected to say something like, “They’re both something that you enjoy.” But this isn’t true for everyone. Do you think that sanitation workers dealing with the smell of your trash go home talking about, “Oh, I just love my job”? No. So tests are linguistically biased against Black populations and the rest of minoritized groups.

The underreferral of Black boys to gifted and talented education and the linguistically and culturally loaded tests are a double whammy that denies our Black boys opportunities to be challenged and reach their full potential.

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Watch the entire interview with Donna Y. Ford and James L. Moore III at Journal of Multicultural Counseling and Development Special Issue – Authors Interview – YouTube.

Scott Sleek is a freelance writer and editor in Silver Spring, Maryland. He specializes in content related to social and behavioral sciences and clinical care.

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.

Essential skill development for meaningful social connection

By Lisa Compton and Taylor Patterson September 18, 2023

A group of adults sitting around a table drinking coffee and smiling

Geber86/Shutterstock.com

Research has identified the important role social connectivity plays in mental wellness. As trauma experts, we also recognize how attachment deficits and trauma wounds can impact components of making and maintaining relationships.

Attachment deficits may cause people to seek friends and partners who possess similar characteristics to their insecure attachment figures (such as partnering with abusive or emotionally unavailable individuals). These deficits may also result in people prioritizing their own attachment needs above the needs of others (as in the case of narcissistic relationships), or they may cause people to disregard their own boundaries to maintain relationships at any cost (such as in codependent relationships).

Unresolved trauma wounds can interfere with healthy connectivity when our survival defense systems are in overdrive trying to protect us from pain. We may react with hypervigilance and misinterpret interactions as potential threats, have difficulty trusting others, maintain rigid boundaries to avoid intimacy, or simply overreact or underreact emotionally to situations. Past trauma can cause both emotional and physiological changes that interfere with social connection. The survival reactions of fight, flight or freeze direct bodily resources to respond to the crisis and move away from activities unnecessary for immediate survival, such as digestion and higher-order functions of the prefrontal cortex. The limited operation of the prefrontal cortex reduces our capacity for executive functions such as reasoning and communication, which are important components in navigating relationships. This reduction in executive function can happen during an actual trauma or may be triggered by a sensation associated with the trauma.

Counselors play a significant role in clients’ social skill development, increasing their potential to interact intentionally and not reactively from defensive responses. To help facilitate these discussions, we created the meaningful connection skills pyramid, a clinical tool counselors can use with clients who have insecure attachment and trauma histories (see Figure 1). This tool identifies six developmental skills that function in a progressive, developmental path toward meaningful connection and aid in intentional interactions: self-awareness and assessment, self-soothing to calm nervous system arousal, connection of past events to current triggers, reciprocal interactions, boundary enforcement, and rupture and repair.

Figure 1: Meaningful connection skills pyramid by Lisa Compton and Taylor Patterson

In the following sections, we illustrate how counselors can use this tool with a hypothetical example: Alicia comes to counseling after she has a significant argument with one of her close friends. When she was scrolling through social media, she discovered that her friend attended a party without her. Alicia was so upset that she called her friend and accused her friend of not caring about her or their friendship. Then Alicia blocked the friend’s phone number and social media accounts. Alicia’s history of trauma has disrupted her ability to reason, communicate with her friend, hear other possible explanations for why she wasn’t invited or work through the relational rupture.

Increasing self-awareness

Self-awareness is a foundational skill in social connection. Socially intuitive individuals can remain aware of internal cues (i.e., awareness of internal states) and external cues (i.e., awareness of how they come across to others). Clients may be interoceptive, the internal awareness of what is happening in the body (e.g., heart racing, feeling a “pit” in the stomach), or neuroceptive, the ability to assess external cues of safety or threat in the context of relationships. For example, an employee may notice that their chest is tight as they approach an important performance review at work (interoception). When they enter the conference room, the boss provides cues of warmth and approachability by smiling, leaning back in their chair and greeting the employee in a friendly manner (neuroception); these cues enable the employee to intentionally engage in calming behaviors and remain grounded throughout the meeting. By increasing our internal and external awareness and recognizing when we are in a threat response mode, we can work toward feeling safe and changing our defensive reactions.

Counselors can use assessment tools to help clients notice, evaluate and describe their level of distress and social connection. Here are three self-assessments we recommend using with clients:

Subjective Units of Distress Scale: This self-assessment tool allows clients to quantify their level of distress on a scale from zero to 10.
Body scans: This method asks clients to pay attention to parts of their body and bodily sensations, starting with their feet and moving up to their head. Body scanning helps strengthen clients’ ability to practice interoception.

Zipper screening tool description of zipper images

Figure 2: Zipper screening (a self-assessment tool created by Lisa Compton)

Zipper screen: I (Lisa) created this tool to help clients quickly assess and describe their current perceptions of social connection (see Figure 2). Counselors ask clients, “How ‘zipped’ or connected to others do you feel right now?” Clients then respond using the metaphor of a zipper to describe how connect they feel: zipper broken (disconnected), zipper functional but unzipped (lonely but hopeful), partially zipped (interacting but unsatisfied) and fully zipped (connected and fulfilled). Clients can also create their own metaphors such as “zipper stuck in the fabric lining” to represent feelings of enmeshment and other distressful forms of connection.
Window of tolerance: Clients can use this tool to evaluate their current arousal levels. The window of tolerance describes the optimal arousal zone (also considered “equilibrium”) between hyperarousal and hypoarousal, where clients remain regulated and the prefrontal cortex is active and functioning optimally. We recommend counselors use a color code to simplify the use of this tool: red for hyperarousal, green for optimal zone and gray for hypoarousal. With this method, clients do not need to remember the terminology; instead, they can respond using colors to indicate how they feel: green (“go” or move forward with treatment), red (too hot and need to cool down) or gray (lethargic and need to be energized). Counselors can teach clients how to expand their window of tolerance through emotion regulation activities and early identification of triggers.

We can help our hypothetical client, Alicia, increase her awareness of physiological cues of distress (interoception) and external cues of safety or danger (neuroception) using these tools. For example, the counselor could have Alicia take the Subjective Units of Distress Scale and reflect on the intensity of her distress at various points in her conflict with her friend (e.g., before seeing the social media post, during the phone call, after blocking her). In addition, the counselor could ask Alicia to identify what sensations she was feeling in her body at each of these points (e.g., stomach felt nauseous, chest was tight, face felt warm). Alicia could also consider what external cues contributed to her distress (e.g., the social media post, her friend’s tone of voice).

Calming the nervous system

It is common for clients with a history of insecure attachment or trauma to try to restore emotional and physiological equilibrium through maladaptive emotion regulation strategies. This can often prompt unhelpful oscillation between hyperarousal and hypoarousal.

For example, because of her traumatic experiences, Alicia finds herself constantly scanning her friendships for perceived rejection. This creates a state of hyperarousal and often intense symptoms of anxiety. To manage her hypervigilance, she drinks heavily in social situations in an attempt to calm her anxiety. The counselor can work with Alicia to help her identify her reactivity. Then she will be able to consider more adaptive emotion regulation strategies, including regulated breathing, progressive muscle relaxation and grounding exercises.

Connecting past events to present triggers

When clients have an emotional response that seems disproportionate to the present circumstances, they are likely reacting to past trauma wounds or attachment deficits. As clients learn to regulate their nervous system arousal, they can begin to cognitively connect their reactivity to specific triggers related to past events.

It’s understandable that Alicia would feel disappointed or confused when she discovered she was not invited to a party, but an amygdala-initiated survival response of fight, flight or freeze does not seem to correspond with the present threat. Once Alicia identifies her reactivity, she can explore past events potentially connected to her current trigger. For example, maybe past experiences of rejection led to negative core beliefs about Alicia’s self-worth, such as “I’m unlovable,” “I’m defective” or “I’m invisible.” In this case, modalities such as eye movement desensitization and reprocessing and cognitive behavior therapy can help clients such as Alicia identify origins of triggers, examine negative core beliefs associated with these memories, and instill more adaptive beliefs to promote healing from past trauma wounds and decrease reactivity to present triggers.

Engaging in reciprocal relationships

Insecure attachment can become trauma responses if the person has unmet needs in infancy and early childhood. Parental responses to infant distress create relational structures that affect how the infant learns to relate to their caregivers and others. Insecure attachment is characterized by chronic misattunement to a child’s needs or emotional experience and can be experienced by the child’s nervous system as a threat to survival. The child learns to adapt to this chronic misattunement through relational patterns such as attention seeking or overattending to the needs of others.

Attachment science has been helpful not only in understanding child-caregiver relationships but also in conceptualizing adult relational patterns. Without intervention, children with anxious, avoidant and disorganized attachment styles can continue to exhibit these patterns in their adult relationships, creating enmeshed, detached or volatile relationship dynamics. But with therapeutic intervention, clients can learn to build and maintain reciprocal relationships, which allows both the client’s needs and the needs of others to be honored and respected. Counseling can also help clients discern safe and unsafe relationships, decreasing the likelihood of repeating unhealthy relationship dynamics established in childhood.

Alicia can now identify her reactivity, practice adaptive self-soothing reactions and connect her triggers to past wounds so that she can begin to practice reciprocal relationships with others. For example, the counselor might suggest Alicia take the risk of planning a social event and inviting others to attend, rather than expecting that her peers will anticipate and act on her desire for connection.

Enforcing boundaries

Reciprocal relationships establish an environment in which boundaries can be set and maintained. Boundaries provide personal guidelines for multiple areas of our life, including our commitments, how we want to be treated by others and how we care for ourselves. Communicating boundaries effectively requires assertiveness, or the ability to clearly communicate one’s needs while respecting the needs and dignity of others. Practicing this skill often requires people to be brave because others may not be receptive to or respect one’s boundaries.

For example, Alicia’s desire for her friends’ approval often caused her to stay out too late, which disrupted her sleep and her ability to arrive at work on time. A personal boundary for Alicia may involve setting a curfew for herself and communicating this to her friends. By keeping her own arousal levels in check and assertively communicating her needs, Alicia creates an environment with less potential for relational harm and higher potential for resolution to relational conflicts.

Managing and repairing ruptures

Every long-term relationship will experience a rupture of connection because of conflict, miscommunication or simply a difference of opinion. How we manage the ruptures determines the level of intimacy and longevity of the relationship. Many people did not have healthy role models in childhood for managing relational conflict. Maybe they watched their parents engage in volatile disagreements or passively avoid conflict; both extremes can make conflict feel threatening and prompt people’s defense mechanisms to engage quickly. It is tempting to avoid conflict and detach from individuals at the first sign of relational difficulties.

Once Alicia has managed her reactivity, moved toward reciprocal relationships and practiced boundary enforcement, she can resist the urge to lash out or withdraw in response to conflict and tolerate the uncomfortable feelings that come from confrontation. Ideally, Alicia would be able to communicate her sadness and disappointment about being excluded from a social event to a safe and trustworthy friend and work toward repairing the relationship. The skills of distress tolerance and active communication enable clients to stay engaged long enough to make genuine repair attempts and invite them to use effective conflict resolution with their partner, friend or colleague. The ability to successfully navigate relational ruptures and repairs builds trust and increases the potential for long-term intimacy in relationships.

Counselors can also model this skill for clients within the therapeutic relationship. In the book Preparing for Trauma Work in Clinical Mental Health, I (Lisa) and Corie Schoeneberg discuss how to have difficult conversations with clients and how to repair the relationship when therapeutic ruptures occur. Regardless of the type of relationship, remaining in the window of tolerance enables us to repair ruptures without defensive reactivity so that we can protect the integrity of the relationship and foster relational intimacy.

Conclusion

The meaningful connection skills pyramid provides a treatment plan for helping clients improve their social skills by progressing along a developmental path. Improving client self-awareness and emotion regulation and their understanding of the connection between past events and current triggers are all foundational interventions for trauma work and other presenting issues, such as marital distress and workplace conflict. Higher-level skills such as reciprocity, boundary work and conflict resolution are invaluable for all relationships and settings. Regardless of trauma history or childhood attachment security, all clients can increase their well-being through improved ability to maintain social connection.

Lisa Compton is a professional counselor with over 25 years of experience. She holds a doctorate in counselor education and is a certified trauma treatment specialist. She is a full-time faculty member in the master’s and doctorate counseling programs at Regent University, an author and a conference speaker.

Taylor Patterson is a doctoral student in counselor education and supervision at Regent University. She is a licensed professional counselor who works primarily with adults with a history of childhood trauma.

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: An accidental advocate shares secrets to success

By Adrienne Griffen September 12, 2023

A woman standing in front of a window holds an infant up to her face. The infant's hand is on her chin and their noses almost touch.

Iryna Imago/Shutterstock.com

I describe myself as an accidental advocate.

Twenty years ago — in the period of life referred to as “B.C.” or “before children” — I never would have anticipated that I would lead national conversations around maternal mental health. I had graduated from the U.S. Naval Academy and was an intelligence officer in the Navy. I went through rigorous psychological assessments to ensure that I was mentally stable and could handle top-secret information. I worked at the Pentagon and the White House, and I aspired to be the secretary of defense or the head of the CIA.

Then I had a baby, and my world changed. I experienced significant postpartum depression, which manifested as rage and feelings of being completely overwhelmed. I had a toddler and a newborn, and I felt like I was drowning. It took me six months to get the help I needed, and I decided during that dark time in my life that I would do something so that other new mothers did not suffer as I did. Thus, I became an advocate.

I learned that mental health conditions (including anxiety, depression and psychosis as well as obsessive-compulsive, posttraumatic stress, bipolar and substance use disorders) are the most common complications of pregnancy and childbirth, affecting 1 in 5 pregnant or postpartum people, or 800,000 families, each year in the United States. Tragically, suicide and overdose are the leading causes of maternal mortality, accounting for almost a quarter of deaths for women in the first year following pregnancy. Each year, 250 new mothers in our country will die by suicide in the months following childbirth — a sobering statistic.

I now serve as the executive director of Maternal Mental Health Leadership Alliance, a nonprofit organization launched in 2019 to focus on national policy around maternal mental health. Working with other organizations in the field, we have successfully championed three pieces of federal legislation addressing maternal mental health, which, if fully funded, will garner $200 million in federal funding over 10 years. All three laws — the Bringing Postpartum Depression Out of the Shadows Act of 2015, the Into the Light for Maternal Mental Health Act of 2022 and the TRIUMPH for New Moms Act of 2022 — were enacted the first time they were introduced, which is notable given that it typically takes seven years for a bill to become law. In the last Congress, over 10,000 bills were introduced and just over 300 were passed, including two laws (Into the Light and TRIUMPH for New Moms) addressing maternal mental health.

How were we able to elevate these pieces of legislation? Here is a list of 10 things we learned along the way:

Think of advocacy as education. Many new advocates feel overwhelmed by the concept of advocacy and lobbying, and I have learned over the years that the best way to make them feel comfortable is to describe advocacy as education. I explain that everything we do as advocates — from telling our stories to writing articles to testifying before Congress — is focused on raising awareness and offering solutions.
Incorporate the voices of lived experience. Most advocates in the field of maternal mental health have lived experience with these conditions and can speak passionately about how they or their families were affected. Each year we bring together advocates from across the country for a virtual Advocacy Day, meeting with members of Congress and their staffers, and the personal stories are always the ones that have the greatest impact.
Don’t hesitate to be an advocate. Anyone can be an advocate. Along with individuals with lived experience, medical and mental health professionals who work in maternal mental health are effective advocates because they are subject matter experts and provide information, knowledge, perspective and experience.
Add facts and figures. While personal stories move hearts, data moves heads. We weave statistics in with stories and distill important facts into short sound bites that are both easy to say and easy to understand. For example, when explaining that 1 in 5 childbearing people are affected by mental health conditions, I say that we all know someone — whether that person is our mother, grandmother, aunt, sister, daughter, friend or neighbor — who has experienced maternal mental health conditions. The goal is to make information less abstract and more relatable.
Keep it brief. Practice telling your story. Hit the high points with a few facts and your “why.”
Take baby steps. Advocacy can be as simple as reposting an article on social media. Even small actions can make a difference.
Be nonpartisan. Our work focuses on mothers and babies, which are topics that everyone can support.
Choose congressional sponsors wisely. All the maternal mental health legislation that we have advocated for had bipartisan and bicameral sponsors on committees of jurisdiction. Lead sponsors in the House and the Senate were from both parties and were on relevant appropriations subcommittees.
Cultivate a broad range of advocates. Members of Congress always want to hear from their constituents, so we cultivate a broad range of advocates from across the country, including both individuals with lived experience (grassroots) and experts in the field (grasstops). We often tap our advocates to follow up with specific congressional offices so that members know what their constituents are thinking and how they are affected.
Focus on relationships. We stay in touch with our legislative champions and advocates throughout the year, ensuring they have the latest information about maternal mental health. This includes follow-up emails after Advocacy Day, in-person visits when we are on Capitol Hill, shout-outs on social media, newsletters with policy updates and advocacy tips, and organizational sign-on letters that bring additional voices to our cause.

If you are interested in learning more about maternal mental health or becoming an advocate, check out MMHLA’s website, sign up for our newsletter, follow us on social media or email us at info@mmhla.org.

If you or someone you know needs support while experiencing a maternal mental health condition, contact the National Maternal Mental Health Hotline (1-833-TLC-MAMA), which provides 24/7 voice and text support in English and Spanish.

Adrienne Griffen (agriffen@mmhla.org) is the executive director of Maternal Mental Health Leadership Alliance, a nonpartisan 501(c)3 nonprofit organization dedicated to improving mental health care for mothers and childbearing people in the United States, with a focus on national policy and health equity. Follow MMHLA on social media: LinkedIn, Instagram and X, formerly known as Twitter.

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

Coping with the loss of a supervisee to suicide

By Keith Myers September 11, 2023

two white flowers with black ribbon lying beside a lit tea candle

Marharyta M/Shutterstock.com

Four years ago, I awoke to an email from my supervisee. She thanked me for being a great supervisor, and I thought, “Oh good, she’s going to find another supervisor for a diverse perspective.” But then I quickly realized that this wasn’t a typical exchange. In the next few lines, she said she was ending her life. The tone was resolute and final.

When I read those words, everything stopped. My vision blurred. It felt like I had entered a dark portal that was transporting me into an empty, dark abyss; the portal disappeared behind me, removing any chance I had of getting out. I was stuck, floating almost outside my body. I was in shock.

Moments after the loss

The word supervisee feels so formal and professional, almost sterile. It falls short in describing my connection to this person I had lost. We had spent over 100 hours of supervisory time together during the three years I had been her supervisor. That’s a lot of time. Our relationship was primarily professional, but she had attended my dissertation defense and met my wife, so the professional sometimes merged with the personal.

In the moments after reading the supervisee’s email, my mind started to race with thoughts: Is this real? When did she send the email? Is she alive? Maybe she tried and failed. Is she in pain? How did I miss this? Why would she do this? I have her address; I’m going over there. I should call her.

There is something in our spirit that wants to deny the reality of a deep and sudden loss.
In the email, she thanked me for my supervision, my encouragement and mentoring, and she encouraged me to “fight the good fight.” My first thought was, “Easy for you to say.” But then I realized that it hadn’t been easy for her.

During supervision, she talked about being recently diagnosed with a mental illness and how challenging it was for her and how she didn’t want to keep living like that. I wanted to let her know she wasn’t alone, so I shared that I had witnessed how difficult it could be because I knew someone who had the same mental illness.

I also wanted to tell her that one of my close family members currently struggles with this mental illness, but I didn’t. Sometimes I wonder if disclosing that would have made a difference — not the difference of her dying or living but helped her feel less alone. But maybe that is just the natural feeling we get after loss where we think we could have done something more.

Advice for coping with suicide loss

I have lost several clients to suicide, but I have always been able to differentiate myself from my clients and their decisions and struggles, even ones that result in them ending their lives. I tell my counseling students, “Attach to the person. Detach from their outcomes.”

But the loss of my supervisee was different. It was unfathomable. Because I had been her supervisor, I felt a greater sense of responsibility to her, and this caused me to reflect more on how I could have done things differently. I think it’s natural to evaluate your role when things go wrong. With time and consultation with a mentor, I realized that I had done everything I could. But some of the weight of this loss still remains with me today.

Classes don’t prepare us to cope with client losses, much less the loss of a supervisee. So, I doubt anyone has received training on how to cope with this unless it has been by a mentor who has experienced something similar. Loss by suicide is something we should talk more about — for ourselves as humans and clinicians.

Losing my supervisee to suicide taught me a few things about grief and loss. Although my experience is unique to me, I hope that by sharing what helped during this difficult time, I can help other supervisors and counselors who may experience the loss of a colleague or client at some point in their careers.

Let yourself feel — without judgment. I realized early on that I needed to allow myself space and freedom to feel a host of emotions, such as sadness, hurt, anger, betrayal, guilt and empathy. I never thought this would happen to one of my supervisees, so allowing myself to experience these emotions without judgment helped me process what I was feeling.

We also have to remember that we need to embrace and process these feelings before we act or attempt to find a new purpose. After the memorial service, I sat in my car and thought about what I would do differently because of her death. But my emotional part spoke up and said, “You need to wait. You need to feel your grief before you discover some grand new purpose.” I am grateful I listened to that voice inside me. Allowing yourself to feel before thinking and doing is a healthy response to a shocking loss.

Seek support from others. In my 20-year career as a mental health counselor and 13 years as a counselor educator, I have realized that we do not talk enough about how therapists can cope when a client dies by suicide. So, when it happens, counselors often find there is little professional or peer support. I realize the loss of a supervisee is uncommon; anecdotally, I asked 12 supervisors who had a cumulative 290 years of supervisory experience, and none could recall ever losing a supervisee through suicide. Trust me, you would more than recall if it happened to you. It is forever etched in my heart and soul.

Many counselors receive supervision at the agencies or hospitals where they work. However, since I am an independently licensed counselor in private practice, I was not receiving weekly supervision when my supervisee died. I was just doing monthly consultation. But I knew that I needed more than a monthly check-in during this time, so I asked a colleague who is a trauma-trained supervisor to be my regular, weekly supervisor for the next several months. I knew it was important to have additional and consistent professional support through this season of my life. The supervisor knew about my loss and was always mindful of ways in which I might have been projecting my grief onto my clients or any traumatic countertransference I may have been experiencing. The supervisor was comfortable addressing and exploring these concerns with me if they arose.

I advise colleagues to join a suicide support group. I know that support groups can feel daunting for some, and there may be an issue where the therapist knows the clinician leading the group or has clients in the group. You could also talk to a friend who is a suicide survivor or reach out to your support systems or another mental health professional. Lean on the people who love and support you.

Begin or revisit individual therapy. In addition to supervision, it’s important to be in therapy when coping with suicide loss. I hadn’t seen my therapist in several months, but it helped me find relief and validation for how I was feeling. After I told her what had happened, she looked at me with a blank stare and said, “I never.” Those two simple words resonated with me and affirmed how I felt in that moment. I never thought it would happen either.

Counseling provided me with a safe space to express the unfathomable. It also served as an additional source of support and gave me insight and awareness I would not have had if I were only in supervision. My therapist helped me explore the helper part of myself, which provided perspective around this loss.

Change your perspective. Metaphors, sayings and stories can help us find meaning during difficult or confusing times and help us gain new perspective. For example, the metaphor “Grief is a stone you carry in your pocket” reminds me that grief is always with us, even in times when we don’t realize it is present. It also illustrates how sometimes grief is smooth and contains wonderful memories, but other times, it has sharp edges that can prick you.

After my supervisee died, I resonated with the saying, “What is grief if not love persisting?” This quote allowed me to see how my grief also illustrated how much I cared for this person. If I hadn’t cared, I wouldn’t have felt it so deeply.

Books can also be a great source of comfort. A colleague and friend suggested I read Albert Hsu’s Grieving a Suicide: A Loved One’s Search for Comfort, Answers, and Hope. I’m thankful for this recommendation because it helped me further process my grief and provided helpful examples from a survivor’s faith-based perspective — something that is important to me. Hsu explained that sometimes suicide survivors view their lives through the lens of the death: Everything becomes what happened before or what happened after the loss. On a spiritual level, that is my truth.

An ongoing process

In the months after my supervisee’s death, I found myself obsessively reading her email over and over again. It was like I felt obligated or compelled to memorize it. Maybe I thought that memorizing it would help me not forget her. I wish I could say that I don’t feel compelled to read it now four years later, but I still do. Every year on the anniversary of her death, I find myself reading it again. My therapist recently asked if part of me is still searching for something in her last words. I don’t know the answer to this question yet because I’m still processing through the loss. Grief is an ongoing process after all.

I hope that none of you will ever face a loss like this. But if you do, know that you’re not alone. Give yourself space to grieve and care for the person you lost and rely on the support of others while you try to find comfort and make meaning of the unfathomable.

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Helpful resources

Grieving a Suicide: A Loved One’s Search for Comfort, Answers, and Hope by Albert Hsu, 2017
Myths About Suicide by Thomas Joiner, 2011
“Supporting survivors of suicide loss” by Dana M. Cea, Counseling Today, 2019
Why People Die by Suicide by Thomas Joiner, 2007

Keith Myers has worked in clinical mental health for almost 21 years and is the founding clinic director of Ellie Mental Health in Marietta, Georgia. He received his doctorate in counselor education and supervision from Mercer University. He is a licensed professional counselor, approved clinical supervisor and an adjunct professor with both Mercer University and Richmont Graduate University. Much of his research focuses on traumatic stress and military issues, which resulted in his first book, Counseling Veterans: A Practical Guide. He works with veterans, first responders, couples and trauma therapists who are experiencing secondary traumatic stress.

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.