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Counselors Audience

Professional advocacy: A call to the profession

By the ACA Advocacy Task Force June 3, 2020

This past year, American Counseling Association President Heather Trepal commissioned a task force to focus on the topic of professional advocacy. This article is part of our response to that charge.

In this article, we discuss professional advocacy and its importance; ways that counselors can advocate; how ACA has advocated for the profession; what all counseling associations can do to support an advocacy agenda; what individual counselors can do to be advocates; and the important role that a clear, unified counselor identity plays in furthering a professional advocacy agenda.

Professional advocacy and its importance

Professional counselor advocacy involves taking action to promote the profession, with an emphasis on removing or minimizing barriers to counselors’ ability to provide services. Although advocacy as a whole has become increasingly relevant over the past two decades, efforts related to professional advocacy have received less attention and therefore made little headway in comparison with client and social issues advocacy.

Counseling is a mission-based profession, meaning that we each had a reason for choosing this career. There was someone we wanted to serve, or some setting or client population for which we wanted to make a difference. All counselors have felt called to be agents of change. In fact, our ethics codes and professional competencies mandate that we advocate for and alongside our clients.

That being said, when we consider advocacy, we do not often think about our mission for our profession. Concerns such as parity (being reimbursed at the same rate as other mental health professionals with comparable training), public recognition, accurate representation of our profession, and employment opportunities are important if we are to practice our craft. We must know and promote our worth and recognize that if we are not strong and healthy as a profession, we cannot help others. Therefore, professional advocacy must be a top priority for all counselors.

Examples of professional advocacy

Advocacy activities serve to expand counselors’ presence at the community, state and national levels, and counselors should not underestimate the importance of supporting the growth of the profession through actions taken in their local communities. In addition, professional advocacy activities include those aimed at positively promoting the counseling profession.

Larger-scale advocacy actions could be conceptualized as capital “A” advocacy actions, whereas smaller-scale advocacy efforts could be called lowercase “a” advocacy actions. For example, “A” advocacy actions might encompass large, organized efforts such as those aimed at changing federal or state legislation or local policies and practices. They can include teaching and supervising students through setting standards, developing competencies and applying ethics. They are our shared responsibility to unite our voices.

Examples of “a” advocacy actions include those continuous, in-the-moment efforts that positively promote the counseling profession. These efforts may generate positive cultural change regarding counseling, help-seeking or what it means to be a counselor. These efforts can also include mentoring our next generation of professionals.

An important point is that neither “A” nor “a” advocacy actions are more or less important. Both types are needed, and we all have our role to play in professional advocacy efforts.

Today, counselors face myriad barriers to providing care to students, clients and communities. These barriers include the Medicare coverage gap, lack of licensure portability, inadequate funding for mental health treatment across settings, inadequate funding for school counselors, and a lack of public knowledge about counseling as a profession. In addition, the rising cost of graduate education often leaves professional counselors across all settings struggling to pay back student loans years after degree completion.

Each of the aforementioned barriers makes it difficult for counselors to provide care to the people and communities that need them most. For example, if an older adult whose primary insurance is Medicare cannot access the services of a licensed professional counselor, then their options to receive services become limited. When a counselor crosses state lines and cannot work in their new community, it is unjust to both the counselor and the community, especially because there is a nationwide shortage of counselors. Inadequate funding of counseling services means that counselors are not compensated appropriately and that clients cannot access services critical to their well-being. Inadequate student-to-school counselor ratios harm both students and school counselors. In each example, counselors, clients and communities are negatively affected by barriers at the sociopolitical level that prevent counselors from doing their jobs.

What ACA does to advocate for the profession

As an organization dedicated to the counseling profession, ACA has advocacy at the core of its mission. ACA staff, leadership, task forces and committee members work to raise awareness about the profession and support legislation that helps counselors serve myriad communities. By advocating for recognition, compensation and resources, ACA helps counselors continue to perform integral work.

Guided by its 2018-2021 strategic plan and framework, ACA’s advocacy efforts on behalf of the profession involve both legislative and nonlegislative means. For example, ACA continues to advocate for seamless portability across states for independently licensed counselors. To support counselors, ACA recently funded an initiative to pursue an interstate compact for portability. The advisory board for the compact brings together lawmakers, licensing board members, counseling professionals and others to work on advocating for licensure portability.

ACA also employs a team of government affairs and public policy staff members dedicated to advocating with federal, state and local governments on the legislative front to support the profession. These staff members’ efforts, along with those of other counseling organizations and individuals, helped counselors become eligible to provide services through the Department of Veterans Affairs (VA). ACA continues to advocate for more employment opportunities for licensed professional mental health counselors within the VA. ACA also uses an electronic legislative advocacy alert system that all counselors should sign up to receive; by clicking on a link, you can quickly advocate for the profession.

As part of its focus on advocacy, ACA has formed multiple member-led groups to identify the needs of counselors, raise awareness of what counselors do and how they impact communities, expand employment opportunities for new professionals, educate on professional development, and provide information to help counselors advocate for the profession and meet the needs of clients. By harnessing the passion, vision and energy of its members, ACA is invested in training counselors to advocate for the profession, educate the public and promote the needs of counselors and those they serve.

ACA is also working hard to raise awareness of the importance of good mental health. One significant example is ACA’s role in developing Counseling Awareness Month activities. This past April, the Counseling Awareness Month theme encouraged counselors to #BurnBrightNotOut. ACA introduced a Counseling Awareness Month toolkit containing social media resources, fact sheets, contests and sample proclamations that members could use to encourage leaders and governing bodies to recognize counselors and the profession. In addition, ACA promoted Teal Day on April 10. This was a day for counselors to wear the symbolic color of teal to promote the profession. According to the toolkit, “As an outward symbol of advocacy and hope for counselors and the profession, ACA created Teal Day: an enthusiastic social initiative designed to build strong support, recognition and appreciation for professional counselors.”

Suggestions for the profession

Through leadership and advocacy efforts, we have made great strides as a profession in establishing ourselves as vital to the mental health landscape. United, our advocacy efforts have made an impact on critical issues such as insurance reimbursement parity, licensure in all states, and increased consumer awareness of counseling and its value. All of these efforts are vital to our profession and ultimately make a positive impact on the wellness of our clients and communities.

Nevertheless, our profession continues to face threats, so we must never take these successes for granted. Instead, we must double down on our efforts to fortify the health and wellness of the profession moving forward. Ample opportunities exist for growth around professional advocacy initiatives.

One way we can further develop our advocacy efforts is by institutionalizing advocacy supports and structures within counseling organizations. For example, this may include establishing and maintaining an ACA committee, with multiorganizational representation, that focuses solely on the advocacy needs of the profession. ACA, Chi Sigma Iota (CSI), the National Board for Certified Counselors (NBCC), state branches, ACA divisions and other counseling organizations could also build within their structures an advocacy mentoring program. That way, those who have successfully engaged in advocacy efforts — whether legislative, organizational or community advocacy — could share their experiences and pay it forward so that a greater number of counselors would be well prepared to engage in advocacy efforts.

Counseling associations might also create a listing of local “advocacy leaders” as a resource for those facing advocacy challenges and needs in their workplaces or communities. Having the support of a colleague is sometimes all that is needed to encourage a counselor to engage in professional advocacy and help them navigate their way through such efforts. Within and across counseling organizations, spaces can be created for counselors to discuss, connect, consult and get support around advocacy needs.

Collaboration between or within counseling organizations may also provide opportunities for expanding existing advocacy efforts. For example, CSI currently publishes “Heroes and Heroines” interviews on its website, highlighting the lifetime work of highly established counselors who possess a depth of advocacy experience. Three times per year in its online newsletter, the Exemplar, CSI also publishes “Advocacy Agent” interviews with members currently engaged in advocacy efforts. Working together, ACA and CSI could bring these advocacy efforts to an even greater number of individuals through a collaborative advocacy-centric newsletter. Jointly, the organizations could also expand the audience of such efforts through social media, where they could also collaboratively broadcast important advocacy issues, needs and required action.

Furthermore, ACA and CSI members could collaboratively review and offer feedback on revised CACREP standards during the open-comment period to ensure that the standards reflect current and evolving real-world professional leadership and advocacy needs.

Finally, ACA can enhance cross collaboration among ACA divisions and branches by setting up regularly scheduled briefings in which division leaders share advocacy challenges and successes and gather support. One current example is an effort by ACA’s government affairs and public policy staff to host a monthly Advocacy Power Hour with state branch leaders.

Counselors should also engage in interprofessional advocacy. By identifying community partners and potential collaborators, we become stronger and can move more efficiently toward reaching our professional goals.

We are aware that many counselors struggle with understanding how to effectively advocate; they want to help but do not know where to begin. Thus, another way the profession can promote advocacy is through education, both on advocacy directly and on the leadership skills needed to engage in advocacy.

CACREP requires counseling programs to address leadership development. However, training on leadership is not often visible in master’s-level curricula, nor is it prominent in doctoral curricula. Intentional efforts to increase such education is vital.

This leadership and advocacy education can be accomplished in many ways. One means of ensuring that counselors are well armed to engage in advocacy is by making existing leadership and advocacy resources readily accessible. The ACA Conference offers a prime opportunity to promote advocacy education through advocacy-focused educational tracks; an advocacy booth in which resources, networking and support are offered; a keynote speaker focused on advocacy (perhaps with a legislative collaborator); special sessions in which legislators can share and demystify their experiences of working with counselors; and specialized preconference sessions that offer advocacy training.

ACA can further bolster advocacy education through the creation and promotion of short how-to advocacy videos. These videos could focus on inspirational stories of advocacy efforts, with details of how the advocacy got started and what was accomplished. Other videos might fortify our collective professional identity by effectively communicating who we are as a profession and highlighting how we are distinct from other mental health fields. This would help every counselor maintain their pride in the profession.

Additionally, professional associations and organizations could provide webinars on leadership and advocacy to their respective members. They could also create toolkits for counselor educators so that leadership and advocacy training are better represented in master’s and doctoral education.

Advocacy education could also be promoted via Counseling Today, the Journal of Counseling & Development, ACA division journals and other professional literature. These publications could offer dedicated space for featuring research and best practices in leadership and advocacy. Through collaborative, comprehensive, consistent and intentional efforts, counselors can continue to be empowered and united in our efforts to promote the profession, which in turn promotes the wellness and dignity of those in the communities in which we serve.

Suggestions for counselors

Professional counseling organization advocacy is just one piece of the puzzle. The counseling profession never would have evolved if not for the work of individual counselors, and nowhere is that as obvious as with regard to legislative advocacy. Generally speaking, legislators care most about what their constituents think. In fact, individual counselors working in unison with their legislators have facilitated the bulk of the legislative changes that impact our practice.

Each of us has a story to tell about how the law either helps or hinders our work as counselors. Rather than accepting that we have to do our best in a broken system, we must identify barriers that others may perceive to be immovable givens. Sometimes this means taking up the fight — a process that can feel foreign and intimidating, but it is important if we are to thrive.

A simple place for counselors to start is to analyze our social networks and the relationship resources in our own backyards. Who are the power brokers you may already know who can serve as cheerleaders for your cause? Take time to reach out strategically and build relationships. Find reasons to contact a member of your board of education, your religious leaders, a state legislator or your public health administrator. Support efforts in your local community that are consistent with your values, regardless of whether those efforts are directly related to your role as a counselor. For example, counselors can send emails or make calls to support a bill to increase funding for preventing human trafficking or for increasing resources for responding to community crises.

Become visible, and make your presence known. These relationships can be crucial, sometimes in unexpected ways, when you need to advocate for the counseling profession or for the students or clients you serve. When it matters most and when efficiency is essential, those lines of communication will already be open. A counselor constituent might reach out to that one lawmaker who will take up the cause and become a policy champion, thereby influencing others to join the effort. That one lawmaker may determine whether a great idea eventually becomes a law. In sum, individual relationships and networking count. 

Unfortunately, upstream factors such as funding, bureaucracy and scarce resources may cause social services and other constituencies to compete against each other. It is often said that those who are not at the table will not be able to eat. Speaking out about what you or your clients need, either as an individual or, ideally, with your ACA branch or division, and establishing a place at the decision-making table can lead to changes that positively affect the lives of individual clients.

Indeed, such advocacy can also make your work much easier, more efficient and more effective. Counselors should consider how various state or federal government agencies either support or challenge the work of professional counselors. Are there job descriptions and real opportunities for counselors to be employed in the broad variety of settings where other mental health disciplines are already accepted or embraced? Are there loan forgiveness programs that need to include counselors? The need for counselors to be integrated into the VA system and Medicare reimbursement are examples of significant challenges. A natural response to these injustices and barriers to people getting access to care is to become angry or frustrated. Individual counselors who connect with this frustration can use it as momentum to courageously enter unfamiliar territory, including the legislative world.

State counselor practice acts and the licensure boards that enact these laws play an extremely important role in the landscape of our profession. It is helpful for counselors to develop relationships with their licensure board members. Sign up for their email alerts, and take any opportunity you can to forge relationships with them. Attend their meetings if they are public. Seek appointment to serve on the board. Let them know what you need and where you see counselors and consumers struggling. Then encourage others to do the same. Licensure board members are public servants tasked with protecting the public, and many of the issues with which our profession struggles have a significant impact on consumers. Similarly, school counselors can forge connections with their state board of education members.

Professional counselors can help policymakers, members of their local communities and members of their social networks better understand the importance of counseling and the benefit we bring to our clients and communities. Making sure that the power brokers in your respective areas and social circles are aware of counselors’ value is an important task. We know that counseling services help our clients and students to feel supported, reduce their stress and anxiety, and increase their daily functioning. Transferring this knowledge to others is important.

Helping others understand the impact of our work and the ripple effect that counselors have on their communities ultimately influences the profession in various ways. Increasing awareness of counseling’s value can help reduce stigma associated with mental illness and mental health issues. When others understand that 1 in 4 people are living with a mental illness and that our work as professional counselors aids in creating positive change, we can more effectively decrease stigma in our communities. When mental illness is destigmatized, people who need counseling and support are more likely to seek that help in pursuit of living more fulfilling lives.

The importance of a strong counselor identity

A foundational element of effective professional advocacy is a clear professional identity. Unless we know who we are, we cannot communicate that message to stakeholders. ACA, CSI, NBCC, CACREP and other professional counseling organizations have helped to steer counselors toward a shared professional identity. Development of the ACA Code of Ethics, support of CACREP educational and training standards, and the adoption of competencies set forth by ACA divisions are among the ways our profession has worked to define and support counselor identity.

The public’s lack of knowledge about counseling as a profession is an additional barrier to services and is intrinsically tied to legislative barriers. Legislators may not have enough knowledge about professional counseling to make laws that create equitable access across professions or for all clients. Similarly, when managed care companies are not aware of the valuable care that professional counselors can provide, we may be inadequately reimbursed. Even potential and current clients may be unaware of the unique professional identities of counselors and thus misunderstand or undervalue our services. It is critical that we educate the public, including lawmakers, on who we are and what we do.

We work in an increasingly interdisciplinary world. Thus, counselors must work to expand public knowledge and awareness about the services, skills and training provided by professional counselors. As suggested by Stephanie Burns in a 2017 article in the Journal of Counselor Leadership and Advocacy, every counselor should have a one-minute professional identity “elevator speech” that they can share with others. Such a speech can succinctly communicate who we are and what we do to support public understanding of our work.

Some practice settings require counselors to work alongside other mental health professionals under titles such as caseworker or therapist. Similarly, clients may be called consumers or patients depending on the setting. It is important for counselors to use the word “counseling.” When able, counselors should refer to themselves as counselors, not as therapists or guidance counselors, and be clear about who they are as unique helping professionals.

We cannot expect to thrive in an interdisciplinary world if the public does not understand who we are. Educating the public about important issues related to mental health and well-being continues to be an essential role of counselors.

In summary, the counseling profession has come a long way, but we still have work to do. Counselors continue to experience many barriers that get in the way of our ability to practice. All counselors, and all of our professional associations and organizations, have an obligation to commit to and work toward advocacy efforts that will grow our profession.



ACA Advocacy Task Force members who contributed to the development of this article were (in alphabetical order) Angie Cartwright, Madelyn Duffey, Louisa Foss, Cheryl Fulton, Denise Hooks, Victoria Kress, Christine McAllister and Jordan Westcott. Direct questions or comments regarding this article to task force chair Victoria Kress at victoriaEkress@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.

Mental imagery as an intervention for emotion regulation disorders

By Katie Gamby and Michael Desposito May 5, 2020

Although many evidence-based practices emphasize addressing the cognitive aspects of mental health disorders, research suggests that we may be missing helpful interventions that do not fall under the  cognitive behavior therapy (CBT) model of “thoughts, feelings and behaviors.” Several predominant CBT models fail to emphasize mental imagery by continuing to equate thoughts only with verbal manifestations. This is best seen in the counseling techniques and interventions of self-talk, thought records and the ABC (activating events, beliefs, consequences) model.

While these techniques should be lauded for alleviating the symptoms of countless clients, there are other clients who are not served by these treatments. We propose that a lack of focus on imagery can either, at best, prolong the course of treatment for clients or, at worst, encourage clinicians to label clients as “resistant” because their images insulate negative affective responses.

Most clinicians in the field tend to neglect mental imagery despite research showing that disturbances in mood and the development of certain forms of psychopathology are often correlated with negative images that contribute to the strength and production of negative emotions. Historically, mental imagery has been difficult to research and measure, but we now have evidence suggesting that mood disturbances and psychopathology can be addressed through imagery work. As professional counselors, our role is to promote a holistic approach to counseling not only by addressing our clients’ symptoms but also by focusing on the prevention of those symptoms in the first place.

Mental imagery can be defined as the representation and experience of sensory inputs without a direct stimulus. Several theories have been proposed for the creation of mental images, but bio-informational theory is the one that we will be discussing. In this theory, there is a strong connection between imagery and emotion. This connection is attributed to physical and behavioral reactions to images. For instance, negative images, in comparison with neutral images alone, often produce more negative emotional reactions (e.g., imagining yourself stuttering as you give a future speech in public increases anxiety about future speech performance).

What does neuroscience say?

From a neuroscience perspective, mental imagery is consistently implicated in the propagation of certain emotion regulation patterns. Research shows that this may occur because there is overlap between different areas of the brain based on the type of perceived image. There appears to be brain activity that overlaps between the frontal (cognitive function and voluntary movement/activity) and parietal (sensory processing) areas of the brain regardless of imagery content, but there is also some overlap between the parietal and occipital (visual processing) areas of the brain. This suggests a top-down process when retrieving information from long-term memory.

Damage to the occipital lobe can make it difficult for people to produce images, especially when they try to recall past memories. Neuroimaging also suggests a correlation between visual cortex activation and a person’s subjective rating of the vividness of an image. This could explain why it is easier for someone to recall a memory that has an emotional component to it (sometimes called a flashbulb memory).

This seems to suggest a connection between episodic memories (i.e., two people who experience the same event can have a drastically different recollection of that event) and how a negative autobiographical memory can influence future behaviors. If I continue to imagine potential future situations negatively (imagining all future speeches going poorly, for example), the likelihood is that my present and future will align with those images. If I can create a positive future image (future speeches going smoothly), I am more likely to rewrite my present, negative autobiographical memory to be more positive and, therefore, influence both my past and future self toward positivity.

Benefits for clients

Working with mental imagery in counseling offers several benefits. First, it should be noted that imagery work integrates a person’s cognitive, emotional and somatic aspects, with primary focus placed on the emotional aspect. This is important to consider because although clients might rationally “know” that something is true for them, they can still remain “emotionally stuck” in their past maladaptive behaviors. Counselors who work with images may be able to get around the rational “knowing” and actually address clients’ emotional connections to their images.

Second, imagery is often taught as a skill or to reinforce other skills. Because mental imagery connects different aspects of the brain, imagery has been shown to increase imagination and memory capacity. Additionally, teaching imagery as a skill can help clients realize their power over their own images.

For instance, both of us have used a simple image of a cupcake with a raspberry on top of it with clients. We ask clients to look at the picture of the cupcake and then close their eyes (if comfortable doing so) and imagine the cupcake in all its detail. Then we ask them to change the cupcake in the image they are envisioning, removing the raspberry and replacing it with a blueberry. By being able to manipulate the cupcake image in this way, clients can work up to practicing changing more negative images that elicit negative emotions for them. For example, perhaps clients can imagine themselves providing an eloquent speech without stuttering. Or a speech in which they stutter but are able to remain calm and collected regardless of how well they speak. There are many different ways of teaching mental imagery skills to assist clients that are outside of the scope of this article.

Third, there are several specialized areas beyond mental disorders that seem to benefit from the application of imagery work. For instance, imagery can help clients cope with current problems by allowing them to explore all sides of the issue in vivo and visualize outcomes and other alternatives. Not only can clients effectively problem-solve in this manner, they can get to the heart of emotional components that are often connected with their decisions. Mental imagery encourages clients to take into consideration the temporal nature of situations by helping to reconstruct future beliefs about identity, which in turn increases goal setting and motivation. Connecting imagery to a plan or viewing goals with imagery can increase confidence and belief that one can accomplish them.

When applied to grief work, imagery can help clients work through their grief reactions by allowing them to revisit scenes that are connected with the loss in the past. In addition, positive imagery can be promoted to help clients confront impulses in cases of nonsuicidal self-injury or even to improve outcomes of sports training. Interestingly, mental imagery has also been implicated in healing from sports injuries by decreasing subjective pain responses.

Imagery and emotion regulation

Mental imagery also plays a pivotal role in a number of mental health disorders. For example, intrusive images are considered part of the diagnostic criteria for specific disorders such as posttraumatic stress disorder (PTSD) and often are hinted at in criteria discussing “thought” processes connected to anxiety, bipolar disorder and obsessive-compulsive disorder. Typically, these distressing images match the core concerns of the presenting issue and work to insulate the distressing emotions by acting in tandem with other symptoms. Examples of this might be clients who have obsessional thoughts about insects experiencing images of insects on their bodies, clients with test anxiety experiencing future-focused images of themselves failing a test, and military veterans with PTSD returning home from active duty and reexperiencing traumatic memories during fireworks displays.

The clinical significance of understanding mental imagery when treating clients with emotional dysregulation is of utmost importance. Recent research supports the notion that when compared with verbal content, imagery elicits stronger emotion and can even have an amplifying effect. For example, when an image promotes anxiety-provoking content, it can increase a person’s anxiety. Likewise, it can amplify positive messages, such as when imagining positive outcomes through imagery rehearsal for an upcoming public speech.

Given that the “realness” of images (or a lack of image production) can influence a person’s belief in said images, it is imperative for counselors to understand the content of client images to better provide intervention strategies. Client perceptions of the “realness” of their images appear to add to the power of the content, influencing not just emotions and behaviors but also beliefs.

A strategic clinical intervention

There are several ways to promote imagery as a clinical intervention. The five specific strategies that follow are summed up based on how they can be utilized in session. These interventions, although different from each other, also overlap at times.

1) Competition to imagery: When planning counseling interventions, it can be wise to follow the adage of “fighting fire with fire” to promote the greatest reduction of symptoms in the shortest amount of time. In this instance, “competing” with tasks that use similar cognitive resources can serve to reduce the distressing vividness of the images. This is due to “overloading” the brain. The competition strategy differs from distraction coping techniques because the imagery is being processed simultaneously.

This strategy is often one of the first steps in systematic desensitization for phobias because pairing mental imagery with relaxation often has a therapeutic effect of lowering distress to the said phobia. This is because a client cannot feel both anxious and calm at the same time physiologically. It is also theorized that this is why eye-movement desensitization and reprocessing works — the clinician’s use of bilateral stimulation while the client’s image is exposed overloads the brain and reprocesses the image.

2) Exposure to imagery: One of the most common and best practice techniques occurs by exposing clients to intrusive or distressing images. The reason exposure works is because it addresses images that cause increased emotional dysregulation, allowing clients to regulate themselves over time. Eventually, the client will see an image and not have a negative emotional reaction toward it. Exposure therapy continues to show documented evidence of lowering client distress toward the images during the therapeutic protocol.

3) Imagery retraining: Retraining or “rescripting” imagery seeks to train clients to produce positive images in response to neutral environmental cues or to adapt a distressing image into a more neutral form. This is especially helpful in cases of depression because a lack of positive future images appears to insulate depression symptoms. With either method — producing positive imagery or adapting a more neutral form — the critical process seems to promote alternatives to the client’s current image or lack thereof.

In some sense, producing positive imagery is a relatively new idea. The counselor seeks to encourage the production of positive images in response to ambiguous cues to in turn help clients produce more positive images to novel stimuli. One aspect of the computerized training known as cognitive bias modification is an example of this strategy. Research suggests that this strategy alleviates depression symptoms in clients through the promotion of positive images about the future.

4) Imagery questioning: While the “realness” of mental imagery seems to predict the quality and impact of the images, another strategy used to address imagery is to examine the mental representations themselves. This is similar to the verbal thought work of CBT. With the rise of mindfulness and third-wave behavior therapies such as acceptance and commitment therapy, counselors could take a metacognitive approach to their intervention strategy for images. The object of this type of imagery is to question the “truth” of the image being reported and to promote client functioning. A client would be encouraged to go back to the image and address its truth (i.e., did everyone really laugh at me during my speech? Did I really stutter the whole time I was talking?). Now remembering the image more realistically, the client has the capacity to recall the image as it actually occurred.

5) Transformational imagery: In this work, clients are encouraged to produce an image and modify, adapt or manipulate it (rotating spatially) to promote autonomy over the image and to decrease the occurrence of distressing images. Being able to control the image allows clients to provide a safe place for themselves within a distressing image, transform the image into something different (e.g., transforming a snake into a balloon) or otherwise manipulate the image (like what we did with the cupcake mentioned earlier in the article). This is similar to imagery questioning but also promotes client empowerment to control the image themselves. Guided imagery, as a technique, is an example of this strategy in which images are transformed as an outcome of the intervention.

Steps to integrating imagery into clinical work

When addressing mental imagery in counseling, counselors should weigh the benefits and risks of incorporating the tool in sessions. As professional counselors, it is imperative that we complete thorough assessments to help us determine whether clients are stable enough to address their images. If not, it may be appropriate to first provide them with some coping tools and techniques to increase safety. Second, for imagery work to be effective, clients must be able to produce images. This is also an important piece of assessment.

A simple way to do this is by asking clients to visualize an important family member or friend who produces positive feelings in them. Then invite clients to tell you what this person looks like from head to toe. If clients do not have someone who meets this criteria, find a picture of an object, ask clients to view the picture for one minute, talk to them afterward for a few minutes, and then come back to the picture and ask them to draw that image up in their heads and tell you what they see. If clients are unable to bring back the image, they may not be appropriate for imagery work and would need further assessment.

As with any intervention we use, we need to provide our clients with appropriate informed consent and discuss the potential benefits and detriments of doing imagery work. Clients need to be informed that imagery can produce intense emotions, but providing some information about why that is might help lessen their anxiety about the process. Additionally, the therapeutic relationship is still of the utmost importance; clients must trust in the relationship to be able to get the most benefit out of therapy. Counselors may want to seek additional training to address client imagery. This can help counselors feel better prepared to engage with mental imagery and to work with clients from a variety of backgrounds. 


Our hope is that all counselors have access to interventions that will assist their clients in getting better. As all counselors in the field know, some interventions work seamlessly with certain clients and just don’t work with others. The more competent we are with the interventions we have to address client concerns, the more we will be able to do great work. We believe mental imagery is one intervention that professional counselors can add to their toolboxes to increase the quality of care provided to clients.



Katie Gamby is a licensed professional counselor and assistant professor at Malone University in Ohio. Her research and writing interests include client wellness, mental imagery, schema therapy, and spiritual bypassing. She enjoys serving the state of Ohio through multiple professional organizations. Contact her at kgamby@malone.edu.

Michael Desposito is a licensed professional counselor at a private practice in Ohio and president of an Ohio state counseling division. He has presented at national, state and local conferences on a number of topics, including emotion regulation and mood disorders, affirmative therapy and pedagogy practices for LGBTGEQIAP+ populations, and wellness. Contact him at wellifestylecounseling@gmail.com.


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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.

Jane Myers and Tom Sweeney: Servant leaders and advocates for the counseling profession

By Allen Ivey and Mary Bradford Ivey April 30, 2020

We have known Jane Myers and Tom Sweeney for over 20 years, during which time we collaborated on writing projects related to a mutual passion: helping to promote the well-being of all people.

When Jane died of cancer in 2014, it was a great loss to us personally and to the profession of counseling as a whole. Recently, we felt moved to interview Tom about Jane, as well as their substantial contributions to the evolution of the counseling profession.

Tom and Jane are the only [husband and wife] couple who have both been presidents of the American Counseling Association. They made a significant difference in their time as presidents, but they were equally influential as active members of ACA’s governmental structure.

Before turning to the interview we conducted with Tom, we’d like to touch on some of the areas in which Tom and Jane helped to shape the profession. During our interview, Tom shared some stories associated with several of these accomplishments.

The origins of ACA’s name: What we know today as the American Counseling Association began as the American Personnel and Guidance Association in 1952. The name was occasionally derided by some (“guidance is for missiles”), but it stuck until 1983, when I (Allen Ivey) introduced an alternative: the American Association of Counseling and Development (AACD). I thought the name spoke to the goals of counseling and implied a wellness/health orientation. The association thus changed its name and operated as AACD until 1992. Despite this, the concept of “development” was largely unclear to the public at that time. So, eventually, Jane and Tom helped propose our identity as simply the American Counseling Association. This three-word title succinctly defines who we are to the public.

Social justice: Jane and Tom remained social justice advocates throughout their careers. Tom, the son of Scottish immigrants, grew up in a racially and multiculturally rich community. As early as 1968 in what had been a segregated state university, he planned and directed the first in a series of fully integrated six-week-long summer institutes for 50 counselors from 13 Southern states living together in a dormitory. These and other programs were funded by the General Electric Foundation Educators in Industry program.

Jane’s brother had developmental disabilities. Her mother, a special education teacher, imbued in Jane a genuine love and respect for people with disabilities. Jane’s counseling career began as a state vocational rehabilitation counselor. By her own report, Jane’s administrator thought her too strong of a social justice advocate on behalf of her clients. So, Jane went on to earn a counseling doctorate, during which time she learned of the needs of older adults. Thus began her efforts in gerontological advocacy, research and teaching.

One of Jane’s gerontology students once told her that as this student was entering Jane’s classroom, a colleague professor of Jane’s said, “Don’t go in there. That area is irrelevant.” Finally, we are seeing these clients as central to our work as counselors.

Licensure: Tom took a first step toward counselor licensure in 1974, when he proposed licensure for counselors in an article titled “Licensure in the helping professions: Anatomy of an issue.” (More about this topic in the interview.)

Accreditation: Preparation standards are the foundation for counselors’ scope of practice and ethics. Accredited educational programs are crucial for professional creditability. The clear definition of standards directly impacts counseling curricula and staffing. Tom (1981-1987) and Jane (1994-1996) both chaired the Council for the Accreditation of Counseling and Related Educational Programs (CACREP). In addition, Jane almost single-handedly helped to establish a gerontological curriculum, competencies and CACREP specialty through Administration on Aging grants. She also won approval from the National Board for Certified Counselors (NBCC) for a national certification in gerontological counseling. Sadly, neither of these specialties exist today within CACREP or NBCC.

Chi Sigma Iota (CSI): In 1985, Tom and Jane established the first counseling honor society chapter (Alpha) at Ohio University. Both served as president and executive director of CSI. CSI has more than 130,000 initialed members, has chartered more than 400 university-based chapters, and is the third-largest active membership organization in the counseling profession.

Since its inception in 1985, CSI has returned over $1.7 million to university chapters and members through rebates, awards and grants. Its goal is “to promote a strong professional identity through members … who contribute to the realization of a healthy society by fostering wellness and human dignity.”

CSI’s leadership style is based on Robert Greenleaf’s philosophy of servant leadership — i.e., one serves to benefit the greater good of others rather than for self-interest.

Wellness: Jane and Tom began their work related to wellness in the 1980s. Through their research, writing and teaching, they helped provide a foundation and focus that increasingly defines what it means to be a professional counselor.

A gallery of portraits of American Counseling Association presidents is featured in a hallway at the ACA headquarters office in Alexandria, Virginia. Jane Myers is visible in the middle row, second from right. Photo by Bethany Bray/Counseling Today

An excerpted interview with Tom Sweeney

Allen Ivey: Could we turn to those basic important struggles you had in the early days?

Tom Sweeney: Looking back, sadly, I had thought that we could be both collegially professional counselors and psychologists. As background, I have a minor in counseling psychology, belonged to the counseling psychology Division 17 [of the American Psychological Association until the mid-1970s], and was a licensed psychologist because we had no Ohio counselor licensure yet. I worked early on, and even as president of ACES (Association for Counselor Education and Supervision) and ACA, to build cooperation and dialogue with Division 17, AAMFT (American Association for Marriage and Family Therapy) and other groups. Jane did as well during her term as ACA president. Cooperation was not forthcoming, and psychologists have consistently fought to stop or limit counselor practices. Many still do today.

ACA supported starting NBCC because we knew the battle would be long and hard fought. Now all states have counselor licensure, but the battles in the marketplace continue.

Mary Bradford Ivey: You and Jane have been central in leading and supporting state-by-state licensing, CACREP and Chi Sigma Iota. These are awesome contributions that have made counseling a full profession. How did all this start for you?

Tom: The short answer is I learned in my doctoral studies that counseling was an “occupation,” not a profession. From my early leadership years, I sought to bring counselors into the family of helping professions through counselor credentialing, standards of preparation, ethics and accreditation.

When I wrote the first article on “Licensure in the helping professions: Anatomy of an issue” (1974) for the APGA journal, we were far behind psychologists. The Ohio state psychological board was new and aggressive in asserting its authority. The next year, I was commissioned to write what became the APGA Governing Council-adopted position paper on counselor licensure. I chaired both the first SACES (Southern Association for Counselor Education and Supervision) Licensure Committee (1972) and then the APGA Licensure Committee (1975-77). As a consequence, I networked with counselors all over the country who were being impacted by psychologists’ efforts to advance their members’ practices. I traveled, spoke and testified on occasion at legislative hearings.

I can still recount the aggressive actions of psychology licensing boards. The most notable case for me was the state of Ohio psychological board having an African American Ed.D. counselor arrested on felony charges for providing assessments for parents whose kids couldn’t get tested for special ed placements. I got personally involved, and we (APGA) sent a friend of the courts brief. The judge dismissed the case but made no ruling.

Another case in Virginia got a favorable review by the judge, and Virginia became the first state to have counselor licensure as a result. A member of our licensure committee, Carl Swanson, was instrumental in both of these cases. Every state attaining licensure was different thereafter, and literally hundreds of counselors made it possible.

Allen: And then there is CACREP, a necessary foundation for our profession. You and Jane were central here.

Tom: As president-elect of APGA/ACA, I knew that without accreditation, licensure efforts would be even more difficult. I am pleased to say that I made the APGA motion to adopt the ACES Standards for Counselor Education for the first time ever. Until then, there were no recognized APGA-endorsed standards.

As President, I wrote the position paper establishing CACREP. Joe Witmer was CACREP’s first executive director, and I was the first chair for CACREP’s initial, critical, formative six years. Lots of stories associated with these early years. Deans of colleges openly opposed us.

One of our most important tasks was revising standards in those early years. CACREP is accountable to the members of the profession and the public that we serve through the process of standards revision and implementation. Change in higher education moves slowly because of tradition, expense and reluctance to create unintended consequences. I don’t think we as a profession are unique in this regard. Of late, some might argue that change has gone too quickly in some regards, especially related to online education and its entrepreneurial rise to power in higher education. Not just in our field but in the medical field and others as well.

Nevertheless, the role of CACREP is critical as a foundation for helping to define our scope of practice. In some ways, CACREP helps us define what is meant by “professional counseling.”

Mary: Why was NBCC started?

Tom: NBCC was established because those of us immersed in the licensing efforts knew it would take a long time to establish professional counselor credentials in every state. The Federal Trade Commission was pursuing other professions with too closely enmeshed membership, accreditation and national credentialing bodies, so we opted to keep CACREP and NBCC apart from ACA, even though ACA (APGA) supported each startup with funding and office space.

As APGA president at the time, I remember my Governing Council subcommittee wanting to delete a budget for continuing such an effort. I intervened and got it reinstated by having the committee conduct a survey asking members what they thought. It got the largest mail survey result of anything AGPA had attempted before — and members wanted their membership association to support their accrediting and credentialing bodies.

Mary: What does NBCC do for us professionally?

Tom: When we first conceived of what then was called national “registers of service providers,” we thought it would fill in as a credential for those members who had no prospect of a state license for years to come. Once licensure was established in all jurisdictions as it is now, we thought the national credential would fade away.

I’m probably not the one to ask, as my involvement over the last decades has been limited to some collaboration between CSI and NBCC. Under the leadership of Tom Clawson, NBCC’s advocacy and outreach programs have gone far beyond whatever we could have imaged in 1982. As with Carol Bobby’s CACREP leadership, they have advanced counseling as an important partner in promoting professional counseling throughout this country and abroad.

Allen: And along with all that, you and Jane founded our profession’s honor society, Chi Sigma Iota.

Tom: Yes, Jane had started the Rho Chi Sigma rehabilitation counseling honor society. It was small, modest numbers, of course, but she made those students feel special through her style of mentoring. When I say her mentoring, a few years ago, the winter edition of the Journal of Counseling & Development (JCD) had articles by six of Jane’s graduates. Last year, five received various national awards. We all learned from the very best! This is the kind of mentoring that she helped model in CSI.

So, witnessing Jane’s honor society chapter spirit, I saw its potential for the profession as a whole. Many faculties in other programs were struggling for a professional identity, so I decided to create a way for students, faculty and graduates to claim their professional identity through an honor society dedicated to all counseling specialties, all degrees, etc. We mailed one letter of invitation to counselor educators across the country, and we never needed to send another.

Today, programs seeking CACREP accreditation also want CSI chapters since we are known to be co-curricular partners within counselor education programs. For example, the CSI Executive Council recently adopted a position of leadership and advocacy for counselor identity and wellness that will find its way into all of our chapters and beyond.

Mary: I recall clearly Jane’s 1990 presidential address on wellness over the life span. It was exciting, as I was once a physical educator in the Madison, Wisconsin, schools, where health had been central to my work. And on hearing Jane’s address, I immediately understood what needed to be done to support her direction. My work with Allen on therapeutic lifestyle changes was reinforced by her ideas.

Tom: Yes, Jane was a visionary. As president-elect (1989-1990), she got a resolution passed to state unequivocally AACD’s “support for the counseling and development profession’s position as an advocate toward a goal of optimum health and wellness within all of our society.” It was about this time that our wellness research was just getting off the ground. With our Ohio University colleague Mel Witmer, we developed the WEL inventory and began collecting data for Jane’s database.

Allen: Tell us more about your and Jane’s solid research and work on wellness and assessment instrumentation.

Tom: With substantial help of a world-renowned statistician, John Hattie, we used Jane’s database of several thousand subjects to conceptualize an empirically derived Indivisible Self Wellness Model (ISWEL) and to create the Five Factor Wellness Inventory (5F-Wel). With Jane’s help, I was able to use Adlerian theory to provide practitioners and researchers with concepts and means to advance their clinical and scholarly work based upon a practical theory and sound empirical model. The instrument has been translated into over a dozen languages.

An article in JCD (2020) with Laura Shannonhouse as senior author affirms the usefulness of the adult 5F-Wel. After a rigorous screening process of over 100 studies down to 59 that met their criteria, the authors reaffirmed that it is suitable for both research and clinical practice. There were insufficient reports as yet for teenage and elementary reading levels.

I continue to receive what had been Jane’s correspondence from individuals from all over this country and abroad in counseling, education, psychology, nursing and medicine. Our instruments and empirically based Indivisible Self Wellness Model are cited far and wide beyond our field.

Mary: The four of us had the pleasure of writing a book that brought counseling, wellness and development into an integrated package. As we conclude our discussion, it might be helpful if we talked about the “how” of a developmental/wellness-oriented counseling and therapy practice.

Tom: Like you folks, Jane and I became convinced that holistic wellness was a better construct from which to define counseling goals and outcomes.

Our Indivisible Self Model has 17 factors (e.g., positive humor, thinking, nutrition, etc.) that practitioners can incorporate into any client’s treatment plan regardless of the presenting issues. Rather than focus only on problems, we focus on client strengths and what they can do now to take steps toward optimizing the totality of their quality of life as much as possible.

Counseling has long been a wellness and positive development profession. Both developmental counseling and therapy (DCT) and Adlerian practice focus on the strengths one finds in all clients. Both are fully aware of social influences in the session. Wellness is central to both and has its own proven system to encourage demonstratable therapeutic lifestyle changes. One does not need to embrace all the tenets of Adlerian or DCT to effectively implement a wellness counseling approach, but if you do, it certainly will help.



Allen and Mary Bradford Ivey have written, keynoted, and presented workshops throughout the world for nearly 40 years. Allen is distinguished university professor (emeritus) at the University of Massachusetts, Amherst. Mary has been recognized nationally as having developed one of the top 10 guidance programs in the United States. Both have been honored as fellows of the American Counseling Association. Allen and Mary were also founders and former president and vice president of Microtraining Associates, an educational publishing firm focusing on counseling and therapy skills and the first in the nation to present educational videos on multicultural approaches to counseling and therapy. Contact them at allenivey@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.

Adjustment disorder in the time of COVID-19

By Laura Sladky April 21, 2020

The inability to leave home; constantly accessing the 24-hour news cycle; fervent hand-washing and disinfecting; increasing anxiety; sleeplessness. These are just a few facets of the world’s new “normal.”

Doubtless, the COVID-19 pandemic has highlighted the necessity of personal hygiene and the fragility of life. But while projections of decreased mental health states have been rolling in aside a slew of seemingly never-ending bad news, the media have generally failed to normalize the struggle for (nearly) everyone to adjust to this new way of life.

As professional counselors, we are braving telehealth, juggling our own mental health needs amid those of our clients, and helping friends and family members adjust to uncertainty and unemployment, all while trying to pepper in some self-care and generally navigate this unprecedented time for ourselves.

To begin, I would like to normalize adjustment disorder for ourselves as professionals. Depending on the timeline of our geographic location’s response to COVID, we may be relatively early in the process of testing, diagnosing and surviving this pandemic. As a result, most of us (understandably!) meet the criteria for emotional and behavioral symptoms in response to an identifiable stressor occurring within three months of the onset (read: the genesis of COVID-19 and adjustment disorder). Furthermore, we are remiss if we do not acknowledge our own social and occupational impairment as a result of this pandemic.

I share this not to wallow in the current reality but to normalize it. I see my friends and colleagues pouring out their every waking moment to address the needs of clients and families alike. Most counselors have seen a rise in their caseloads as the result of COVID-19, many times taking on new clients without having met them in person. Given these circumstances, truly, when are counselors given the space and time to not be whole? To not “have it together”? To not have the “answers”?

On a personal level, I have consumed more coffee, slept more disruptedly, worked out more, and nibbled on more snacks than I care to admit. I have unceremoniously become a school counselor who works from home (with a 12-step commute) and shares “office space” with my spouse. My cat is thrilled by the constant access to affection, but I cannot help but view my life in terms of discontinuity and extremes.

To you, my dear friends, comrades and colleagues, I say that we are in an unprecedented time with no predictable end date. We are responsible for ourselves both personally and professionally. We must take care of ourselves before we can help others (similar to the guidance we give to our clients). We must practice self-care. We must resist the urge to assuage our lack of control with overexposure to the news. We must resist the downward spiral.

A favorite text to which I often return in trying times or times of uncertainty is The Upward Spiral: Using Neuroscience to Reverse the Course of Depression, One Small Change at a Time by Alex Korb. In this accessible text, Korb highlights how seemingly everyday behavior can improve our neurochemistry and continue to spiral us upward toward healthier levels of functioning. Lately, the aspects of this text I have found most salient are:

  • Work it (out): “Movement increases the firing rate of serotonin neurons, which causes them to release more serotonin.”

Fortunately for those of us quarantined at home, there is an endless supply of free streaming content from major workout companies, live workouts from trainers, and general gym enthusiasts who are willing to share their routines online. Whether you are a novice or a natural, make sure to get your body moving daily.

  • Set goals: “We are often under the impression that we are happy when good things happen to us. But in actuality, we are happiest when we decide to pursue a particular goal and then achieve it.”

This may seem counterintuitive in a crisis, but setting goals for ourselves can help increase our personal happiness. Personally? Running a marathon on my balcony won’t spark much joy, but for you, it might.

  • Get outside: “Bright sunlight helps boost the production of serotonin. It also improves the release of melatonin, which helps you get a better night’s sleep. So if you’re stuck inside, make an effort to go outside for at least a few minutes [in the middle of the] day. Go for a walk, listen to some music, or just soak in the sun.”

I cannot stress this enough: Whether it’s in between seeing clients or on your lunch break, if safety allows, please get outside. Nature provides us one of the most natural ways to improve our mood and connect to something larger than ourselves. This also might be an excellent time to assist your local animal shelter by taking some furry friends out too.

  • Maintain a sleep/wake schedule: “[Q]uality sleep is essential for learning and memory. In particular, sleep selectively enhances memory for future-relevant information, which helps you be more effective at achieving your goals. Furthermore, sleep enhances the learning for rewarding activities, which means you’ll have an easier time focusing on the positive.”

The best thing about sleep is that it resets reality and let’s us try again tomorrow; the worst thing about sleep is that it seems harder to attain in times of high stress. One of the best ways to ease your way into REM is to develop and uphold a sleep schedule that creates predictability for your body between night and day. Resist the urge to check your phone, consume caffeine or alcohol, work out, or engage in emotionally stimulating activities before bed. When we sleep at regular intervals, we are able to do our best thinking.

  • Practice gratitude: “Gratitude is powerful because it decreases envy and increases how much you value what you already have, which improves life satisfaction.”

This one hits differently, doesn’t it? We encourage our clients to practice gratitude and mindfulness often, but how much do we really practice it ourselves? I have recently encouraged myself (OK, maybe held an intervention with myself after a COVID-centered news binge) to begin the practice of physically writing down what I am grateful for on a daily basis. In my “regular life,” I often dismiss this practice on account of time and because it is something I “practice in my head.” Now that I am swimming in nothing but time, I am honing my practice.

While I cannot offer my friends and family members a timeline for this pandemic, I can offer them hope. While I cannot change each aspect of the world that is hurting, I can render psychological first aid to my corner of the world, help clients improve their mental health, and continue to grow despite hard times. Finally, while I cannot (and will not) offer my colleagues empty platitudes about how we can “live, laugh, love” our way through this, I will remind each of you that you are not alone. Your struggle is not a weakness, but rather a sign of your humanity. You are allowed to embrace your adjustment disorder to your new normal, and when you do, I’ll be right alongside you.












Laura Sladky is a licensed professional counselor intern and licensed chemical dependency counselor who currently works as a school counselor in Dallas, Texas. Contact her at l.perry09@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.

The need for standardization in suicide risk assessment

By Gregory K. Moffatt April 14, 2020

“I am afraid I might actually do it,” the 31-year-old woman told me. Abigail (not her real name) was referring to ending her own life. For years she had struggled with depression, and she teetered on the brink of suicide. Medication had helped her only minimally. Her ideation was unquestioned and her plan was clear.

These were frightening words to me, and for weeks I held my breath, fearing a phone call from her husband announcing that Abigail had completed suicide. A brief hospitalization had somewhat stabilized Abigail’s life, but she was worn out. Upon her release from the hospital, her husband and I worked together to form a safety plan in an attempt to ensure that he wouldn’t be left a widower and her two children left motherless.

I have seen many clients like Abigail over the span of my career as a licensed professional counselor. Managing clients who are suicidal is a common occurrence in therapy. Data are scarce regarding the percentage of suicidal clients a clinician in general practice might have. However, most of the numbers indicate that up to half of an average client caseload is on the worrisome side of the suicide risk continuum. That percentage is far greater, of course, among clinicians who work with specific populations or disorders that have been shown to have increased risk for suicide. Abigail fell into one of these high-risk categories. Yet as recently as 2006, a meta-analysis by Stefania Aegisdottir and colleagues published in The Counseling Psychologist basically indicated that clinicians aren’t very good at assessing risk. That is frightening.

Equally disturbing is research showing that about one-quarter of us will experience the loss of a client to suicide during our careers, but many (if not most) of us are poorly prepared to manage suicide risk. In a 2013 study by Cheryl Sawyer and colleagues of 34 master’s-level counseling students, 15% reported no confidence at all and 38% reported little confidence in their ability to assess for suicide risk, whereas only 3% reported feeling fully competent to manage suicide risk.

But the problem isn’t just with graduate counseling students. In spring 2017, I presented a workshop for my state professional counseling association’s annual conference. The workshop focused on assessing risk of harm to self or others. I asked the 85 or so participants if they regularly worked with clients who were suicidal. Every hand went up. I then asked if they felt that their training had adequately prepared them for assessing suicide risk. Only two people in the entire group indicated that they felt prepared.

This response is consistent with an article titled “Psychologists need more training in suicide risk assessment” that appeared in the April 2014 Monitor on Psychology. The article, which detailed a task force report and summit organized by the American Association of Suicidology (AAS), said in part, “After three years of study, the AAS task force … called for accrediting organizations, state licensing boards, and new state and federal legislation to require suicide-specific training for mental health professionals.” The article went on to say that “many psychology graduate students are trained only on suicide statistics and risk factors, not in clinical methods of conducting meaningful suicide risk assessments.”

Something is amiss. Not only does it appear that mental health professionals receive inadequate training in this area, but some researchers even question whether the little training we do get has any efficacy. Robert Cramer and colleagues, writing in 2013 about suicide risk assessment training for psychology doctoral programs, stated that “no existing training methods have been investigated specifically in traditional clinical or counseling psychology training settings and samples.”

Although the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders addresses suicide risks by diagnosis, it does not provide any risk assessment tools for clinicians. Given the picture I’ve painted, how can it be that in 2020, we do not have any clear standard — often referred to as best practices — for suicide risk assessment?

Looking back

To identify what blind spots the counseling profession might have, I try to imagine what people will say about our field 50 or 100 years from now. After all, it is easy to look at the past and recognize our errors and oversights. As developmental psychologist Jerome Kagan wrote in Three Seductive Ideas (2000), “If you had lived in Europe as the fifteenth century came to a close, you would have believed that witches cause disease … and that pursuit of sexual pleasure depletes a man’s vital energy and guarantees exclusion from heaven.”

These ideas sound ridiculous today. If you are younger than 30, the following facts from the more recent past will sound equally ridiculous to you:

  • If you were a mental health person in the 1930s, “moron” and “idiot” were formal classifications of what we now call developmental delay. In addition, you believed ice water baths and jumping on a person’s chest could cure schizophrenia.
  • If you were practicing in the 1950s, common treatments for depression included prefrontal lobectomies. Some physicians literally lined patients up and performed these barbaric procedures in 10-15 minutes each.
  • If you were practicing therapy in 1970, you believed that homosexuality was a mental illness. Just a few years ago, some people believed in and actually practiced praying homosexuality out of a person (one of the milder techniques used in so-called “conversion” therapy).
  • In the early 1980s, hardly anyone had heard of AIDS, stalking, Munchausen syndrome by proxy, or autism.
  • When I was in graduate school in the mid-1980s, none of my master’s or doctoral professors even mentioned what we now call “evidence-based” therapies. Cognitive behavior therapy was leading the way, but most of us described ourselves as “eclectic,” and after our supervision hours were satisfied, we all basically did whatever we thought worked.

The lack of exactitude in the mental health field doesn’t end there. When I was a regular lecturer at the FBI Academy in the 1990s, I began receiving calls from around the country about various applications of counseling to law enforcement. One call came from a sheriff’s department. Five officers had been involved in a shooting, and departmental procedure required a fitness-for-duty assessment. The sheriff was asking me to do the assessments, so I began researching this facet of risk assessment and discovered there was no standard whatsoever in the field regarding fitness for duty. It was simply a judgment call on the part of the clinician. Hard to believe, isn’t it?

Apparently, we have a lot to learn. I’m hoping that in the not-too-distant future, therapists will be saying, “Remember back when there was no standard for suicide risk assessment? Unbelievable!”

Risk assessment tools

It would be easy to confuse lack of a standard with lack of tools. We have lots of tools. Among the assessment tools commonly used are the Beck Scale for Suicide Ideation, the Reasons for Living Inventory, the Suicide Probability Scale, the Suicide Intent Scale  and the SAD PERSONS scale, to name just a few. However, there is very little, if any, data clearly demonstrating that one tool is better than another or that assessment tools have any efficacy at all.

One exception is the Beck Scale for Suicide Ideation, which is as well-researched and as validated as any instrument available. But there is still no assumption that clinicians use “evidence-based” assessments. Does that sound a little crazy to anyone but me?

In a 2016 article in the Journal of Psychopathology and Behavioral Assessment, Keith Harris, Owen Lello and Christopher Willcox identified a number of issues with the standard practice of suicide risk assessment, but again, there is no consensus in the field. The authors noted that “an American Association of Suicidology task force … and other experts have called for improved teaching guidelines on valid risk assessment. The findings of this and related studies bring to light weaknesses in current suicide risk assessment and conceptualization, and concerns that some clinical educators and practitioners may be unaware of the limitations of popular tests. There is a clear and present need for updating core competencies for accurate assessment and risk formulation.”

How do we know our assessments are effective?

I’ve never lost a client to suicide, and it would be tempting to suppose that this indicates my system of suicide risk assessment and intervention is effective. However, there are multiple factors unrelated to my competence that might lead to the same outcome. For instance, clients who come to counseling might simply be more motivated to live than those individuals who don’t come to counseling. In such cases, perhaps any adequate therapist would have been effective.

There may be other factors in my clinical work that are the cause of my fortunate success. In other words, perhaps I have been doing something else that works (maybe good rapport or social support), but I’m not aware that this is what is actually helping as opposed to my suicide assessment and intervention. And, of course, I could have been wrong in assuming risk at all. These potential false positives could mean that my clients didn’t kill themselves because they weren’t really suicidal to begin with. And these are just three possibilities.

This is why we need research and standardization. Standardization adheres to accepted research format. My students often start comments and questions with “I think …” or “I feel …” I never let that slide. I don’t care what we think or feel. What do we know? That is what research — evidence-based practice — helps us answer.

I understand that my words may be hard to hear. Before evidence-based therapies became the ethical standard, all of us in mental health were doing what we thought worked. Any challenge to our practice was met with a defensive posture, and I was among the clinicians taking that stance. We felt or believed (just like my students) that our methods worked because our clients appeared to get better. We were certain we were right, and maybe we were, but we had nothing concrete on which to base our assumptions. That seems obvious in hindsight, but the thought was new to us at the time.

Some of our clients might have seemed better but really weren’t. Their desire for improvement might have masked symptoms, and we also know that clients want to please us. They might easily have presented their cases in a brighter light than they should have. Other times, they might have been better temporarily but regressed after terminating therapy. We can easily misinterpret our positive feelings about our work as evidence that it is effective. Could we be making similar mistakes right now in risk assessment for suicide?

A perfect case in point is no-harm contracts. One of the things that clinicians seem to agree upon widely is that there are benefits to using no-harm contracts — also called safety contracts — with our clients who are suicidal. Yet years of attempts to validate the efficacy of no-harm contracts have turned up nothing. M. David Rudd, Michael Mandrusiak and Thomas Joiner Jr. noted in a 2006 article in the Journal of Clinical Psychology: In Session that “no-suicide contracts suffer from a broad range of conceptual, practical, and empirical problems. Most significantly, they have no empirical support for their effectiveness.” A 2005 article by Jeane Lee and Mary Lynne Bartlett reported the same thing. In other words, the one thing that almost all of us do has no data supporting its efficacy.

What we risk

When I’m working through clinical issues, I find it helpful to think of what I would say if I were sitting in front of the ethics committee of my licensing board or if I were being scrutinized in court by a hostile attorney. How hard would it be for an attorney to find 10 clinicians who would propose that I made the wrong decision? If all you can say is, “I thought this was a good idea,” then you have a very weak defense.

In such cases, we risk losing a lawsuit and perhaps having our licenses censured, suspended or revoked. The more important risk, however, is that we might fail our clients and they might lose their lives when we could have served them better.

A standard approach

I’m not the first person to notice this problem, of course. AAS, among other groups, regularly focuses on the development of reliable and valid processes for assessing suicide risk, but as of yet, the solutions are elusive. A number of research studies have attempted to address the issue. James Christopher Fowler summarized well in a 2012 article in Psychotherapy when he wrote, “We are not yet in possession of evidence-based diagnostic tests that can accurately predict suicide risk on an individual level without also creating an inordinate number of false-positive predictions.” This summary brings us right back to where we started.

Combing through the research over the years, I’ve narrowed what we know about risk into a three-factor risk model and five components of risk in my assessment process as a starting place for evaluating the efficacy of risk assessment. I’m not supposing that my work is original or that my system is better than another. I’m only proposing that what I present here is consistent with what we know and that it can serve as a starting point for collecting evidence and producing a standard of best practice.

Three-factor model: The three-factor model proposes that clients are at risk or protected from risk in three global arenas: presenting factors, personal factors and protective factors.

Presenting factors include diagnoses (depression, for example), loneliness, divorce, prior attempts, suicidal ideation and other situational factors that put clients at higher risk for suicide. 

Personal factors include pessimism, weak problem-solving skills and minimal coping skills that put clients at higher risk for suicide. Included here are actuarial data. Some populations, such as female African Americans, have been shown to have very low risk for suicide, whereas others are statistically very high (e.g., Native Americans, male Caucasian teens, the elderly).

Finally, protective factors counterbalance presenting and personal factors. This would include healthy relationships, strong social support networks and religious commitment.

Moffatt’s HM4: The model for assessing risk that I use addresses all three factors. My HM4 model has five components of examination — hopefulness, method, means, motivation and mitigating circumstances.

The research is clear. People without hope are at high risk. Sometimes this is called “future orientation.” Regardless, the question is, “What does my client have to look forward to tomorrow, next week or next year?” If the answer is “nothing,” then I’m worried.

Method refers to one’s plan. The more specific and clear the method, the more I’m concerned. “I sometimes think the world would be better if I just didn’t wake up” is a vague plan. “I have been collecting my mother’s medications a little at a time. I have them hidden in my room, and I plan to take them all at once when everyone leaves for work and school” is a very precise plan.

Means has to do with the tools to be used and the ability to carry out one’s method of dying by suicide. One of the children in my practice once said he wanted to kill himself. His method was to invent a robot that would kill him in his sleep. His method was clear, but the means of executing that plan were completely unrealistic. Even if he could have invented such a robot, the likelihood that he would be able to carry out this plan without attracting his parents’ attention was minimal. On the other hand, teens and adults often have much more realistic means and, because of freedom of movement and access to weapons, drugs and other resources, are much more likely to succeed in a suicide attempt.

Motivation refers to the level of desire to follow through and complete suicide. Fortunately for us as counselors, most of our clients don’t want to die. Their motivation is low even though their emotional pain is high. This is why suicide hotlines work. People are so highly motivated to find a solution (having low motivation to complete the act of suicide) that they will call a complete stranger to seek help. 

Finally, mitigating circumstances are issues that are so weighty that they override the other areas of assessment. Mitigating circumstances can either increase or decrease risk for suicide. My concern for a high-risk client might be overshadowed by the person’s religious beliefs about suicide or by their desire to avoid hurting their children, spouse or parents. “I couldn’t do that to my children” is something that I’ve heard many times from high-risk clients. “My uncle committed suicide, and it devastated my father’s family” is another. Readers might recognize that hope is a mitigating factor, but it is such an important one that it has its own place in my model.

Assessment of Abigail

Abigail’s risk was clear. She was in a high-risk gender, age and diagnostic demographic; she had been contemplating suicide for a very long time; and she had a clear plan. She had been in emotional pain for many years and, most frightening to me, she had little hope of anything ever getting better. Her efforts to improve and the efforts of others to help her, in her estimation, had been futile. She had purchased a poison specifically to have it available if she decided to kill herself (method), and it was presently in her possession (means). I am positive she was motivated to follow through because getting the poison was not easy. She was willing to work hard to prepare for her own death, so I could have little confidence that she wouldn’t follow through. 

Among several mitigating factors in Abigail’s case was that she loved her children and didn’t want to abandon them. Also, she was certain that her religion did not permit suicide, and she feared “an eternity in hell” if she killed herself. Also working in her favor was that she possessed at least enough hope to keep our appointments. She was willing to at least try to let me help her even though she was unsure it was getting her anywhere. She came to therapy several times a week and was willing to trust that life might improve. Finally, she pursued medication for her depression and continued to engage in the business of life. 

Abigail is still alive today, and even though she struggles at times, she reports that she is doing better, that her depression has been managed, and that (now a grandmother) she is finding some happiness in life with her grandchildren.


If I sound overly critical of our profession, it is unintentional. It isn’t that I think we don’t know anything about suicide and risk assessment. On the contrary, there are mounds of data on statistics, risk factors, assessing and so forth. I attended a fantastic education session on suicide risk assessment at the American Counseling Association’s 2018 conference. The session was packed out, the presenters were fabulous, and the information provided was very helpful, but the very nature of the workshop demonstrated that we lack clear standards. Nearly all of us seem to be asking the same question: What do we do?

Without a standard for suicide risk assessment, clinicians face two very serious risks. The first and most important is that failure to standardize may leave our clients at risk for self-harm. Just because we have individualized systems that we believe are working doesn’t mean that they are working. The second issue is self-protection in the event of a lawsuit or a complaint against us with our licensing boards. The existence of best practice standards would allow us to defend ourselves.

Although there is no standard assessment for suicide risk currently, it isn’t beyond our grasp. In the 1990s, the medical community began looking at the use of a research-based protocol in emergency room heart treatment. Malcolm Gladwell described this process in his 2007 book Blink. Physicians resented the simple three-question protocol and were incredulous that anyone would suggest that such a simple tool could offer better triage than their professional experience did. Yet data proved that the protocol was superior in saving lives. The protocol is now standard in the medical field. The same process can be achieved in our field as well, but it depends on our profession’s willingness to study it and to accept the results.



Gregory K. Moffatt is a veteran licensed professional counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University in Georgia. 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. He also writes the monthly Voice of Experience column for CT Online. Contact him at Greg.Moffatt@point.edu.

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