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Counselors Audience

A beginner’s guide to client confabulation

By Jerrod Brown and Megan N. Carter September 15, 2020

In the context of mental health treatment, client confabulation refers to the unintentional recollection and formation of false memories, ranging from subtle embellishments to grandiose elaborations. Confabulation may take the form of a true memory being inserted into an incorrect temporal, spatial or event context. In other words, confabulated memories can be based on an actual memory taken out of temporal context, or they can result from the creation of a completely fabricated memory (one not based on a previously held belief, experienced event or memory). Confabulation may also involve the incorporation of confabulated details or events as part of a true memory.

It is important for mental health professionals to remember that people who confabulate are unaware that they are engaging in this memory phenomenon and have no intent to deceive. Clients who confabulate have no conscious awareness that their memory is false; in fact, they often strongly believe that their memory is true. Confabulation can also manifest in verbal or behavioral displays of unintentional dishonesty.

Confabulation is distinct from delusions, which are firmly held false beliefs that follow a consistent theme and result from psychosis, often involving an alteration of lifestyle to accommodate the false beliefs. It is also distinct from malingering, the purposeful deviation from the truth to achieve a desired outcome (e.g., reporting mental health symptoms that are not present to receive disability payments). Although confabulations and delusions may share a common pathophysiology (i.e., they can present similarly), they are separate phenomena.

Confabulation is a complex and confusing topic with an uncertain etiology, and it remains under-investigated within the context of mental health treatment. It is loosely associated with a number of neurobehavioral/neurodevelopmental disorders (e.g., fetal alcohol spectrum disorder [FASD], intellectual disability) and neuropsychiatric (e.g., schizophrenia), neurocognitive (e.g., dementia, traumatic brain injury) and medical health conditions (e.g., Korsakoff’s syndrome, various brain diseases). Adding to this confusion is the fact that confabulation can also occur among individuals with no identified impairments, disorders or diseases when certain factors are present (e.g., memory confusion, an attempt to fill in a memory gap, high-pressure and stressful interviews).

Although the underlying brain processes associated with confabulation are currently unknown, possible causes have been suggested in the research literature. These include:

  • Attempt to preserve self-coherence
  • Attempt at self-enhancement
  • Competing memories varying in strength and emotional significance
  • Executive functioning deficits
  • Fast-paced and stressful interviewing approaches
  • Frontal lobe dysfunction
  • Guided imagery
  • Hypnosis
  • Impaired attentional control
  • Impulsivity
  • Memory encoding and retrieval deficits
  • Memory loss
  • The mistaking of imagined events for real ones
  • Overconfidence
  • Attempt to preserve a sense of self-identity and self-esteem
  • Reality-monitoring deficits
  • Repeated lines of questioning
  • Self-monitoring deficits
  • An eagerness to please (i.e., wants to demonstrate an ability to answer all the questions)

Most commonly observed in the retrieval of autobiographical memories, confabulations can include information inspired by peers, television, movies and social media. Inspirations for confabulation may also occur from overhearing conversations from other individuals (e.g., inpatient treatment settings, group treatment programs, sober support meetings).

Mental health professionals are often unaware of this topic and typically receive little to no training in the implications of confabulation on client populations. Because of its potential to compromise screening, assessment, treatment efforts, discharge planning and placement, confabulation is a crucial clinical phenomenon for mental health professionals to understand and address in practice.

Types of confabulation

There are two principal forms of confabulation: provoked and spontaneous. Provoked confabulations are incorrect responses to questions or situations in which a person feels compelled to respond. Examples of such situations include intake assessments, investigative interviews and testifying in court.

Research has established that the more stressful a situation is perceived to be, the more likely confabulation is to occur. This is why mental health professionals working in criminal justice or forensic mental health settings need to pay particular attention to a patient’s possibility of confabulation, which may lead to inaccurate diagnosis or symptom identification. Additionally, unintentionally misremembered information can derail the legal process if the person provides inaccurate eyewitness information, prematurely waives Miranda rights, provides false confessions to police or enters inaccurate testimony in court. In the worst-case scenario, it could even result in wrongful convictions.

Spontaneous confabulations are not linked to a particular cue. They range from misremembering insignificant information to generating fantastic and grandiose details. They are believed to result from a reality-monitoring deficit in the frontal lobe combined with organic amnesia. Spontaneous confabulations also differ from provoked confabulations in that most patients eventually stop engaging in the behavior.

Provoked and spontaneous confabulations can be expressed either verbally or through behavior. Verbal confabulation involves articulating a false memory, whereas behavioral confabulation involves acting on a false memory (e.g., going to the wrong home because the person believes it is where they live). Regardless of the form they take, false memories can evoke real emotions from clients, who may have a high level of confidence in the accuracy of their recall despite evidence to the contrary.

An example that one of us experienced occurred in the course of a forensic mental health interview with a woman who was subsequently diagnosed with Korsakoff’s syndrome. During the course of the evaluation, it was clear that she had significant difficulty developing new memories but was able to recall long-term historical memories (e.g., childhood autobiographical memories). She described recently babysitting a neighbor’s three preschool-age children, including fixing them snacks and letting them watch television. A report was made to child protective services because of the woman’s significant impairments and concerns about the safety of the young children in her care. A subsequent investigation concluded that the woman had not been left to babysit the neighbor’s young children; this was an apparently confabulated memory.

Screening and treatment

There are various theoretical models to explain confabulation. One implies a failure to suppress memory traces that were used in the past but that are no longer relevant to what the person is currently trying to remember. Another theory posits that the person simply failed to retrieve the relevant memory. Finally, another theory is that the person failed to locate the memory for that time and context and essentially inserted another memory in its place.

Numerous conditions can increase the likelihood of confabulation, including:

  • Dementia
  • Encephalitis
  • FASD
  • Frontal lobe tumors
  • Frontotemporal dementia
  • Herpes simplex encephalitis
  • Learning disabilities
  • Nicotinic acid deficiency
  • Korsakoff’s syndrome
  • Multiple sclerosis
  • Schizophrenia
  • Subarachnoid hemorrhage
  • Traumatic brain injury

Given that confabulation has an unclear etiology, multiple definitions, and statistical and clinical associations with a range of neurobehavioral, neurodevelopmental, neurocognitive and neuropsychiatric conditions, the use of a valid and reliable screening procedure is essential. This will help mental health professionals avoid inaccurate diagnoses and the development of ineffective treatment plans that could exacerbate underlying conditions. Screening areas for consideration during confabulation evaluations include:

  • Abstract and sequential thinking
  • Attention-deficit/hyperactivity disorder
  • Executive functioning
  • History of trauma
  • Sleep
  • Learning capabilities
  • Social skills
  • Memory
  • Receptive and expressive language
  • Sensory processing
  • Source monitoring
  • Suggestibility
  • Prenatal alcohol exposure

While confabulation can occur for a variety of reasons, early identification, support and monitoring are key. Possible screening tools that may be useful include the Nijmegen-Venray Confabulation List and the Confabulation Screen. Use of these tools may provide a beginning analysis for further exploration of this issue. If confabulation occurs but is thought to be due to an organic condition such as Alzheimer’s disease, dementia or FASD, referral for neurological testing is appropriate and can provide insight into which areas of the brain are most affected. This can assist in determining the best treatment approach given the individual’s particular areas of need.

Regarding treatment, specific intervention strategies have been found to be useful with clients or patients who confabulate. These strategies involve:

  • Avoiding confrontation
  • Avoiding leading questions
  • Avoiding sensory overload
  • Avoiding closed-ended questions
  • Using a slow-paced interview format
  • Using collateral sources to confirm self-report
  • Using developmentally appropriate language
  • Reassuring that it is acceptable not to know an answer
  • Checking for comprehension
  • Minimizing stress
  • Providing family/support-person education
  • Allowing for extra processing time
  • Allowing for long pauses and silence
  • Treating underlying mental health conditions
  • Treating underlying physiological conditions
  • Teaching memory diary use
  • Teaching reality-monitoring techniques
  • Teaching self-monitoring techniques

Establishing a therapeutic relationship with such clients requires acknowledgment that their misremembering is not intentional and that it lacks malice. This can be challenging for clinicians for several reasons: countertransference, frustration at not knowing whether a client’s documented previous diagnoses or symptoms are accurate, and an unconscious bias that assumes the recollection of inaccurate memories is the result of the client trying to gain something else (i.e., malingering) such as money or attempting to get out of trouble.

Clinicians should avoid minimizing what the client is reporting or prematurely assuming that the client is deliberately being noncompliant. In fact, clinicians should recognize that the content of confabulations may even provide useful information regarding the client’s perceptions and behavioral approaches. Additionally, as previously mentioned, the confabulated information may result in real emotions for the client that will need to be acknowledged and processed.

Clinicians must be sensitive to the fact that individuals who confabulate may inadvertently thwart treatment efforts because they lack recognition that their recalled memories are false. To both address this lack of insight and ensure the collection of valid and reliable assessments, clinicians should obtain collateral information to support or refute a client’s claims (especially when a false recollection could result in significant consequences). When clear evidence of confabulation is found, clinicians should appropriately document this in the client’s case file and consider this during the entire treatment process (e.g., intake, screening, treatment planning, discharge planning).

Adaptive functioning

Confabulation can affect a person’s ability to take care of oneself (e.g., personal hygiene, dressing, cooking), carry out activities of daily living (e.g., home cleaning, clothing care, financial management), and effectively maintain a social life (e.g., empathizing, reading nonverbal behavior, establishing a social group, engaging in effective communication). These adaptive functioning deficits can also lead to issues with filing forms to obtain government services (e.g., disability benefits, subsidized housing) and gaining access to medical records to ensure high-quality continuity of care, as well as an increased vulnerability to victimization. Hence, those who chronically confabulate may be less likely to be able to live independently and more likely to require a high level of support.

Therefore, clinicians working with individuals who confabulate should consider administering a “gold standard” adaptive behavior inventory to help guide and inform treatment planning. Among these inventories are the Scales of Independent Behavior-Revised, the Vineland Adaptive Behavior Scales Third Edition and the Diagnostic Adaptive Behavior Scale. Similarly, clinicians working with clients who exhibit significant deficits in adaptive functioning, particularly in higher-level skills such as money management, should be alert to possible confabulations.

Although using a standardized assessment to evaluate adaptive skills can be useful in treatment assessment and planning, clinicians should also be aware of certain disorders, such as FASD, in which confabulation may be common and in which standardized testing does not necessarily identify deficits. For example, those with FASD may be able to complete tasks of daily living such as grocery shopping or managing personal hygiene, but they may have poor judgment (and social judgment in particular) that is not measured on typical adaptive functioning scales. For instance, they may be tricked out of money by someone who is “friendly” to them and then have difficulty understanding or explaining the missing money, so they engage in confabulation to account for it.

In such instances, in addition to using standardized testing, clinicians should carefully assess using qualitative analysis of abilities and interactions. This may be particularly important for those with FASD with regard to social skills or other areas of functioning that are difficult to measure. Confabulation may be demonstrated as a way to present a more functional ability with regard to a wide range of adaptive abilities and may need to be addressed through careful clinical interventions.

If adaptive behavior deficits are found, it is the responsibility of the administering clinician to educate the client’s support systems (family, friends, education system) about the practical implications of these deficits. These support systems may need to be relied upon in cases of severe confabulation to ensure client safety and follow-through on the client’s daily life affairs such as attending appointments and medication compliance. Unfortunately, strong support systems can be less common among this client population. Family, friends and teachers may feel distrustful of the confabulating individual because of a misperception that he or she is willfully attempting to deceive them. Clinicians play an important role in intervening in such misperceptions by educating clients’ support systems on the unintentionality of the confabulations and explaining that they are the consequence of cognitive and neurological deficits.


Confabulation can be a serious obstacle in mental health professionals providing effective care and services. It can have a negative impact on intake, screening, assessment, treatment planning, medication/treatment compliance and discharge planning. For this reason, we urge clinicians to pursue self-study and continuing education training via in-person and online courses to expand their knowledge on this complex and multifaceted phenomenon. When a case of potential confabulation is identified, professionals should seek the guidance of recognized subject matter experts who routinely review key research findings on confabulation on at least a quarterly basis.

Finally, additional research is needed to continue establishing evidence-based screening and intervention procedures to identify individuals who may be at increased vulnerability for confabulation. Such screening procedures could be applied prior to clinical interviewing and in the treatment planning process to ensure that the information obtained is of higher fidelity. The use of such protocols would also familiarize users with the social and cognitive risk factors for confabulation, of which many mental health providers currently lack awareness. Through the adoption of such policies and procedures, the possible negative impact of confabulation can be minimized, appropriate intervention approaches can be implemented, and the likelihood of positive outcomes can be increased.



Jerrod Brown is an assistant professor, program director and lead developer for the master’s degree in human services with an emphasis in forensic behavioral health for Concordia University in St. Paul, Minnesota. He has also been employed with Pathways Counseling Center in St. Paul for the past 16 years. He is the founder and CEO of the American Institute for the Advancement of Forensic Studies and is editor-in-chief of Forensic Scholars Today. Contact him at jerrod01234brown@live.com.

Megan N. Carter is a board-certified forensic psychologist who practices in Washington state. Her career focus has been on forensic psychological evaluations in both civil and criminal court proceedings. She has also focused on providing education about fetal alcohol spectrum disorders to mental health professionals.


Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.


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

Grappling with compassion fatigue

By Lindsey Phillips August 31, 2020

Compassion fatigue presents a paradox for counselors and others in the helping professions. As Alyson Carr, a licensed mental health counselor and supervisor in Florida, points out, it compromises their ability to do the very thing that motivated many of them to enter the field in the first place — empathically support those in pain.

Empathy and compassion are attributes those in the helping professions are particularly proud to possess and cultivate. Yet those same characteristics may leave some professionals more susceptible to becoming traumatized themselves as they regularly observe and work with those who are suffering.

Jennifer Blough provides counseling services to other helping professionals as owner of the private practice Deepwater Counseling in Ypsilanti, Michigan. She says many of her clients experience compassion fatigue. One of her former clients, an emergency room nurse, witnessed trauma daily. One day, the nurse treated a child who had suffered horrendous physical abuse, and the child died shortly after arriving at the hospital.

This incident haunted the nurse. She had nightmares and intrusive thoughts about the child’s death and abuse. She started to isolate to the point that she had to step away from her job because she refused to leave her house. She couldn’t even bring herself to call Blough. She just sent a text asking for help instead.

Blough, a licensed professional counselor (LPC) and certified compassion fatigue therapist, asked the nurse to come to her office, but the nurse said she was comfortable leaving her home only when accompanied by her dog. So, Blough told her to bring her dog with her to the session. That got the nurse in the door.

From there, Blough and the nurse worked together to help the client process her trauma. Blough also taught the client to recognize the warning signs of compassion fatigue so that she could use resiliency, grounding skills, relaxation, boundary setting, gratitude and self-compassion to help keep her empathy from becoming unmanageable again.

Defining compassion fatigue

“One of the most important ways to help clients who might be struggling with compassion or empathy fatigue is to provide psychoeducation,” Blough says. “A lot of people don’t even realize there’s a name for what they’re going through or that others are going through the same thing.”

Blough, author of To Save a Starfish: A Compassion-Fatigue Workbook for the Animal-Welfare Warrior, didn’t understand that she was experiencing compassion fatigue when she worked at an animal shelter and as an animal control officer before becoming a counselor. After she started feeling depressed, she decided that she was weak and unfit for her job and ultimately left the field entirely. It wasn’t until she was in graduate school for counseling that she learned there was a name for what she had experienced — compassion fatigue.

According to the American Institute of Stress, compassion fatigue is “the emotional residue or strain of exposure to working with those suffering from consequences of traumatic events.” This differs from burnout, which is a “cumulative process marked by emotional exhaustion and withdrawal associated with workload and institutional stress, not trauma-related.”

Although compassion fatigue is the more well-known and widely used term, there is some debate about whether it is the most accurate one. Some mental health professionals argue that people can never be too compassionate. Instead, they say, what people experience is empathy fatigue.

In an interview with CT Online in 2013, Mark Stebnicki described empathy fatigue as resulting from “a state of psychological, emotional, mental, physical, spiritual and occupational exhaustion that occurs as the counselors’ own wounds are continually revisited by their clients’ life stories of chronic illness, disability, trauma, grief and loss.”

April McAnally, an LPC in private practice in Austin, Texas, is among those who believe that people can’t have too much compassion. Compassion involves having empathy and feeling what the other person does, but we have a screen — an internal boundary — that protects us, McAnally says. “Empathy, however, can be boundaryless,” she continues. “We can find ourselves overwhelmed with what the other person is experiencing. … So, what we actually become fatigued by is empathy without the internal boundary that is present with compassion.”

As Blough puts it, “Empathy is the ability to identify with, or experience, another’s emotions, whereas compassion is the desire to help alleviate suffering. In other words, compassion is empathy in action.”

McAnally, a certified compassion fatigue professional, also suggests using the term secondary trauma. She finds that it more accurately describes the emotional stress and nervous system dysregulation that her clients experience when they are indirectly exposed to the trauma and suffering of another person or animal.

Symptoms and risk factors

Anyone can be susceptible to burnout, but compassion fatigue most often affects caregivers and those working in the helping professions, such as counselors, nurses, social workers, veterinarians, teachers and clergy.

Working in a job with a high frequency of trauma exposure may increase the likelihood of developing compassion fatigue, McAnally adds. For example, a nurse working in an OBGYN office may have a lower risk of developing compassion fatigue than would an emergency room nurse. Even though they both share the same job title, the impact and frequency of trauma is going to be higher in the ER, McAnally explains.

Counselors should also consider race/ethnicity and contextual factors when assessing for compassion fatigue. Racial injustices that members of marginalized populations regularly experience are sources of pervasive and ongoing trauma, McAnally notes. And unresolved trauma increases the likelihood of someone experiencing empathy fatigue, she adds.

Carr, an American Counseling Association member who specializes in complex trauma and anxiety, and Blough both believe the collective trauma resulting from the COVID-19 pandemic and exposure to repeated acts of racial violence and injustice could lead to collective compassion fatigue for all helping professionals (if it hasn’t already).

McAnally, a member of the Texas Counseling Association, a branch of ACA, says the current sociopolitical climate has also affected the types of clients she is seeing, with more individuals who identify as activists and concerned citizens seeking counseling of late. She has found that these clients are experiencing the same compassion fatigue symptoms that those in the helping professions do.

Blough and Victoria Camacho, an LPC and owner of Mind Menders Counseling in Lake Hopatcong, New Jersey, say symptoms of compassion fatigue can include the following:

  • Feelings of sadness or depression
  • Anxiety
  • Sleep problems
  • Changes in appetite
  • Anger or irritability
  • Nightmares or intrusive thoughts
  • Feelings of being isolated
  • Problems at work
  • A compulsion to work hard and long hours 
  • Relationship conflicts
  • Difficulty separating work from personal life
  • Reactivity and hypervigilance
  • Increased negative arousal
  • Lower frustration tolerance
  • Decreased feelings of confidence
  • A diminished sense of purpose or enjoyment
  • Lack of motivation
  • Issues with time management
  • Unhealthy coping skills such as substance use
  • Suicidal thoughts

There are also individual risk factors. According to Camacho, a certified compassion fatigue professional, individuals with large caseloads, those with limited or no support networks, those with personal histories of trauma or loss, and those working in unsupportive environments are at higher risk of developing compassion fatigue.

In fact, research shows a correlation between a lack of training and the likelihood of developing compassion fatigue. So, someone at the beginning of their career who feels overwhelmed by their job and lacks adequate training and support could be at higher risk for experiencing compassion fatigue, McAnally says.

One assessment tool that both Blough and Camacho use with clients is the Professional Quality of Life Scale, a free tool that measures the negative and positive effects of helping others who experience suffering and trauma. Blough says this assessment helps her better understand her clients’ levels of trauma exposure, burnout, compassion fatigue and job satisfaction.

Regulating the body and mind

“Having an awareness of our emotions and experiences, especially in a mindful way, can serve as a barometer to help protect us against developing full-blown compassion fatigue,” says Blough, a member of ACA and Counselors for Social Justice, a division of ACA.

Part of this awareness includes being mindful of one’s nervous system and the physical changes occurring within one’s body. When someone experiences compassion fatigue, their amygdala, the part of the brain involved in the fight-or-flight response, gets tripped a little too quickly, McAnally explains. So, their body may react as if they are in physical danger (e.g., heart racing, sweating, feeling panicky) even though they aren’t.

If clients get dysregulated, McAnally advises them to use grounding techniques to remind themselves that they are safe. She will often ask clients to look all over the room, including turning around in their chairs, so they can realize there is nothing to fear at that moment. She also uses the 5-4-3-2-1 technique, in which clients use their senses to notice things around them — five things they see, four things they hear, three things they feel, two things they taste and one thing they smell.

Research has shown that practicing mindfulness for even a few minutes a day can increase the size of the prefrontal cortex — the part of the brain responsible for emotional regulation, McAnally adds.

Blough often uses the square breathing technique to ground clients and get them to slow down. She will ask clients to breathe deeply while simultaneously adding a visual component of making a square with their eyes. They breathe in for four seconds while their eyes scan left to right. They hold their breath for four seconds while their eyes scan up to down. They breathe out for four seconds while their eyes scan right to left. And they hold their breath for four seconds while their eyes move down to up.

Counselors can also teach clients to do a full body scan to regulate themselves, Blough and Camacho suggest. This technique involves feeling for tension throughout the body while visualizing moving from the head down to the feet. If the person notices tension in any area, then they stop and slowly release it.

Camacho once had a client lean forward and grab the armrest of the chair they were sitting in while talking. She stopped the client and asked, “Do you notice you are gripping the armrest? Why do you think you are doing that?”

The client responded, “I wasn’t aware of it, but I find it comfortable. I feel like I’m grounding myself.”

Camacho, an ACA member who specializes in posttraumatic stress disorder, trauma, and compassion fatigue in professionals who serve others, used this as a teachable moment to show the client how to ground themselves while also having relaxed muscles. She asked the client to release their grip on the chair and instead to lightly run their fingers across it and focus on its texture.

Carr finds dancing to be another useful intervention. “Engaging in dancing and moving communicates to our brains that we are not in danger. [It] allows us to develop and strengthen affect regulation skills as well as have a nonverbal, integrated body-mind experience,” she explains.

Creating emotional boundaries

Setting boundaries can be another challenge for helping professionals. Blough says many of her clients report feeling guilty if they say “no” to a request. They often feel they have to take on one more client or take in one more animal. But she asks them, at whose expense?

Blough reminds clients that saying “no” or setting a boundary just means saying “yes” to another possibility. For example, if a client wants to schedule an appointment on Thursday night at the same time that the therapist’s child has a soccer game, then telling the client “no” just means that the therapist is saying “yes” to their family and to their own mental health.

Blough and McAnally recommend that people create routines to help themselves separate work from home. For example, clients and counselors alike could listen to an audiobook or podcast during their commute home, or they could meditate, take a walk or even take a shower to signify the end of the workday, Blough suggests. “Anything that helps them clear their head and allows them to be fully present for themselves or their families,” she adds.

People can also establish what Carr calls an “off switch” to help them realize that work is over. That action might involve simply shutting the office door, washing one’s hands or doing a stretch. At the end of the workday, Carr likes to put her computer in a different room or in a drawer so that it is out of sight and mind. Then, she takes 10 deep breaths and leaves work in that space.

Exercising self-compassion

“Because a lot of helping professionals are highly driven and dedicated, they tend to have unrealistic expectations and demand a lot from themselves, even to the point of depletion,” Blough says. “Having low levels of self-compassion can lead to compassion fatigue, particularly symptoms associated with depression, anxiety and posttraumatic stress disorder.”

In other words, self-compassion is integral to helping people manage compassion fatigue. “Self-criticism keeps our systems in a state of arousal that prevents our brains from optimal functioning,” Carr notes, “whereas self-compassion allows us to be in a state of loving, connected presence. Therefore, it is considered to be one of the most effective coping mechanisms. It can provide us with the emotional resources we need to care for others, help us maintain an optimal state of mind, and enhance immune function.”

According to Kristin Neff, an expert on self-compassion, caregivers should generate enough compassion for themselves and the person they are helping that they can remain in the presence of suffering without being overwhelmed. In fact, she claims that caregivers often need to focus the bulk of their attention on giving themselves compassion so that they will have enough emotional stability to be there for others.

People in the helping professions can become so focused on caring for others that they forget to give themselves compassion and neglect to engage in their own self-care. Blough often asks clients to tell her about activities that they enjoy — ones that take their mind off work, help them relax and allow them to feel a sense of accomplishment. Then she asks how often they engage in those activities. Clients often tell her, “I used to do it all the time before I became a professional caregiver.”

She reminds them that they can help others only if they are also taking care of themselves. That means they need to take time to engage in activities that relax and recharge them; it isn’t a choice they should feel guilty making.

Self-regulating in session

As helpers, counselors are likely to experience symptoms of compassion fatigue at some point. This is especially true for clinicians who frequently see clients who are dealing with trauma, loss and grief.

For McAnally, that experience came early in her career. During practicum, she had a client with a complex trauma history who couldn’t sleep at night. In turn, McAnally found herself waking up in the middle of the night, worrying about the client. She knew this was a warning sign, so she reached out to her supervisor, who helped her develop a plan to mitigate the risk of compassion fatigue.

It almost goes without saying that counselors should take the advice they give to their own clients: They should establish a self-care routine. They should seek their own counseling and support. They should set boundaries and find ways to recharge outside of work. And they should exercise self-compassion.

But counselors also need to find ways to self-regulate during sessions. “If you are tense and you’re hearing all of these heavy stories, you’re at a much greater risk of being vicariously traumatized,” Blough says. Self-regulation can provide a level of protection from that occurring, she notes.

Blough often uses the body scan technique while she is in session. Doing this, she can quietly relax her body without it drawing the attention of her clients. In addition, as she teaches relaxation skills to her clients, she does the skills with them. For example, she slows her own breathing while teaching clients guided breath work. That way, she is relaxing along with them.

Likewise, McAnally has learned to be self-aware and regulate her nervous system when she is in session. If she notices her heart rate accelerating and her stomach clinching when a client is describing a painful or traumatic event, then she grounds herself. She orients herself by wiggling her toes and noticing what it feels like for her feet to be touching the ground. She also looks around the room to remind her brain that she is safe.

McAnally also uses internal self-talk. She will think, “I’m OK right now.” As with the body scan, this is a subtle action that clinicians can take to ground themselves without the client even being aware that they are doing it.

Helping the helpers during COVID-19

Recently, Carr received a text from a counseling mentor who has been practicing for 40 years that said, “I am falling apart. I am lost. I don’t know what to do, but sending a text to someone I trust felt right. Write or call when you can.”

Carr quickly reached out, and her colleague said he was experiencing a sense of hopelessness that he hadn’t in many years. He worried about his clients and feared he wasn’t doing everything he could for them. He was also anxious about finances; several of his clients had become unemployed because of the COVID-19 pandemic, so he started seeing them pro bono. All of this was taking a toll on him personally and professionally.

Before the pandemic, McAnally managed her compassion fatigue symptoms in part by checking in with other therapists who worked down the hall from her office and by participating in in-person consultation groups. Now that she is working from home full time because of the pandemic, she says that she has to be more intentional about practicing self-care and accessing support. She calls her colleagues to check in, practices mindfulness, and schedules breaks to go outside and play with her dog.

Even when counselors recognize that they need help, they can encounter barriers similar to those their clients face. For instance, they may not be able to find in-network providers, and only a small portion of the hourly rate may be covered by their insurance. This problem made Carr pose some questions: “Who is helping the helpers right now? How can we take care of others if we aren’t able to more easily take care of ourselves?”

Then she decided to take action. She created Counseling for Counselors, a nonprofit organization dedicated to raising awareness about the emotional and psychological impact on mental health providers during a time of collective trauma. The organization’s aim is to generate funding that would allow self-employed licensed mental health professionals in need of treatment to more easily access those services.

“Although the heightened state of anxiety around the pandemic may have exposed this critical need, the demand for quality, affordable mental health care for counselors is ongoing,” Carr says. “Counselors are not immune to trauma and, now more than ever, licensed mental health professionals need access to mental health services in order to effectively treat the populations we serve and to continue to play an instrumental part in contributing to the well-being of society at large.”

Fostering compassion satisfaction

People in the helping professions often feel guilty or ashamed about struggling with compassion fatigue. They sometimes believe they should be immune or should be able to find a way to push through despite their symptoms. But that isn’t the case.

“I think the biggest takeaway when it comes to compassion fatigue is that it’s a normal, almost inevitable consequence of caring for and helping others. It’s not a character flaw or a sign of weakness. It’s not a mental illness. It affects the best and brightest and those who care the most,” Blough says.

For that matter, compassion fatigue isn’t something you “have” or “don’t have,” she adds. Instead, it operates on a spectrum, which is why it is so important for helping professionals to be aware of its warning signs and symptoms.

Blough acknowledges that compassion fatigue is always present in some form for her personally. She often manages it well, so it just simmers in the background. But sometimes it boils over. When that happens, she knows to regulate herself, to increase her self-care and to get support.

It is easy for a negative experience to overshadow a helping professional’s entire day and push aside any positive aspects. That’s why Blough and McAnally both recommend setting aside time daily to list three positive things that happened at work. A counselor or other helping professional could focus on the joy they felt when they witnessed an improvement in their client that day or when they witnessed the “aha!” moment on their client’s face.

Blough often advises clients to journal or otherwise reflect on these positive experiences before they go to bed because it can help prevent rumination and intrusive thoughts that may disrupt sleep. Celebrating these “little victories” will help renew their passion for their job, she adds.

As Blough points out, “Empathy can definitely lead to compassion fatigue, but if properly managed, it can also foster compassion satisfaction, which is the antithesis of compassion fatigue. It’s the joy you get from your work.”



Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.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.

Climate in crisis: Counselors needed

By Laurie Meyers August 25, 2020

On a warming planet, some of the most rapid increases in temperature are being experienced in the Circumpolar North — the area within and, in some cases, just below the Arctic Circle. Overall, the average global temperature has increased by 1 degree Celsius (1.8 degrees Fahrenheit) since 1880.  Two-thirds of that rise has occurred since 1975.

Since the 1990s, warming in the Arctic, in particular, has been accelerating. Researchers say the region is warming two to three times more quickly than the rest of the planet. In some areas such as Canada’s Labrador coast, the annual average temperature has increased as much as 3 degrees Celsius (5.4 degrees Fahrenheit), causing drastic changes in the weather, terrain and wildlife.

This coastal region is home to the Labrador Inuit people, who live in Nunatsiavut, a self-governing Indigenous territory with five communities — Nain, Hopedale, Postville, Makkovik and Rigolet — accessible only by airplane. The communities are not connected by roads. Instead, navigation is via paths over increasingly unstable ice, which is now prone to sudden thaws and pitted with holes. Unpredictable seasons and severe storms have also made it more difficult for the Inuit to get out on the land that has sustained them physically and spiritually for generations. Like other Indigenous peoples, the Labrador Inuit have faced displacement and forced assimilation. Traditional activities such as fishing, trapping, hunting and foraging are not just for subsistence; they are essential practices that undergird the Inuits’ culture and identity. Climate change has disrupted all of this, not only through changes in the ice, but through changes in the wildlife and plants.

But it goes even beyond that. Climate change is affecting the mental health of this region’s residents.

In 2012, the leaders of the communities of Nunatsiavut asked Inuit and non-Inuit researchers to conduct a regional study of the effects of climate change on mental health. More than 100 residents were interviewed as part of a multiyear study. The resulting report shed light on the strong emotions and reactions of the interviewees, who expressed fear, sadness, anger, anxiety, distress, depression, grief and a profound sense of loss.

One of the interviewees attempted to convey what the land represents to the Inuit: “For us, going out on the land is a form of spirituality, and if you can’t get there, then you almost feel like your spirit is dying.”

A community leader expressed an existential fear: “Inuit are people of the sea ice. If there is no more sea ice, how can we be people of the sea ice?”

Ashlee Cunsolo, a public health and environmental expert who was one of the lead non-Inuit researchers, believes that grief — ecological grief, as she and other researchers have dubbed it — is inextricably linked with climate change. She defines it as “the grief felt in relation to experienced or anticipated ecological losses, including the loss of species, ecosystems and meaningful landscapes due to acute or chronic environmental change.”

A clear and present concern

The story of the Labrador Inuit is undeniably heart-rending. Even so, most people probably feel that scenario is pretty far removed from their own lives and losses. After all, as global citizens of the 21st century, our lives are increasingly virtual, and even if we enjoy the great outdoors, the idea of everything we are being bound to a particular land or place may seem alien.

Think about it a little more though. Whether our settings are urban, suburban or rural, most of us have geographic preferences, be they coastal, mountain, bayou, prairie, desert, forest or canyon. It might be where you live now or where you grew up, but it calls to you. And it has changed. That pond where you spent your childhood winters ice-skating no longer freezes hard enough to handle your gliding blades. Your favorite beach keeps losing feet of sand to the ocean. Ski season is now short on both time and fresh powder. Fire is prohibited at your favorite campsite. The city where you live has endured a summer string of 90-plus-degree days, leaving you longing for fall, but that season of cool, crisp air is increasingly elusive. The heat lasts well into September and October, as trees in your neighborhood stubbornly stay green — until they turn brown.

Austrian environmental philosopher Glenn Albrecht calls that feeling — a sense of missing a place that you never left because it has been altered by climate change — solastalgia.

“I think place can be really underestimated, but place attachment is such a part of who we are,” says Debbie Sturm, an American Counseling Association member who serves on the organization’s Climate Change Task Force. “If there’s harm in a place or threat to a place or loss of place, it is a significant loss.”

As an example, the diaspora caused by Hurricane Katrina in 2005 was extremely traumatic, says ACA member Lennis Echterling, a disaster, trauma and resilience expert who provided mental health support in New Orleans in the wake of the storm. In some cases, people desperately fleeing the floodwaters and destruction were barely aware of where they were headed. Many of those who evacuated have never returned.

“There is still a population who have been separated from their homes — their sacred ground,” says Echterling, a professor at James Madison University in Harrisonburg, Virginia. Although that phrase, sacred ground, is most often associated with tribal populations, Echterling believes it is true for all of us — that we all have an intrinsic attachment to place. And climate change will continue to separate people from their homes, he says, citing researchers who forecast that by the year 2050, an estimated 1 billion people worldwide will be climate refugees.

Even those who haven’t been displaced or experienced climate catastrophe may find it hard to avoid a creeping sense of existential dread — or ecoanxiety — as they witness or hear about extreme weather event after extreme weather event. On June 20, the temperature in the Siberian town of Verkhoyansk reached 100 degrees Fahrenheit, the hottest temperature ever recorded north of the Arctic Circle. Researchers say such an occurrence would be almost impossible (a once-in-80,000-years happening) without climate change caused by human activity. In recent years, wildfires have reduced entire California communities to ash, with citizens up and down the coast donning masks to protect themselves from a lingering pall of smoke. In 2018, Hurricane Florence turned Interstate 40 in North Carolina into a river. Hurricane Harvey struck Houston repeatedly over six days in 2017, leaving one-third of the city underwater at its peak. Approximately 40,000 Houston residents had settled in the city permanently after evacuating from Katrina more than a decade earlier.

Every year, the signs of a climate crisis grow more alarming, and the psychic toll can be traumatic. Psychiatrist Lise Van Susteren, an expert on the mental health effects of climate change, coined the phrase “pretraumatic stress disorder” to describe the fear that many individuals are experiencing about disasters yet to come.

Since 2008, the Yale Program on Climate Change Communication and the Center for Climate Change Communication at George Mason University have been conducting national surveys biannually to track public understanding of climate change. The latest survey results, from November 2019, indicated that 2 in 3 Americans were at least “somewhat worried” about global warming, whereas 3 in 10 were “very worried” about it. A majority of those surveyed were worried about the potential for harm from extreme events in their local areas. 

The mental health effects related to climate change extend beyond disasters such as hurricanes and wildfires. Research has indicated a link between rising temperatures and the increased use of emergency mental health services, not just in places that regularly experience hot weather, but in relatively cool areas as well. Higher temperatures have also been tied to increased levels of suicide.

As the ACA Climate Change Task Force reports in its fact sheet (currently under review), experts predict a sharp rise in mental health issues such as depression and anxiety, posttraumatic stress disorder, substance abuse and suicide, in addition to outbreaks of violence, resulting from coming climate crises. The task force views the counseling profession’s strengths-based approach and focus on resilience as essential to responding to those affected by climate crisis.

However, as part of a study that has not yet gone to press, Sturm, fellow ACA and task force member Ryan Reese, and ACA member Jacqueline Swank surveyed a group of counselors, social workers and psychologists about their personal and professional perceptions of climate change. Although Sturm, Reese and Swank found that these helping professionals were more likely than the average person to believe that climate change is real, very few felt the issue was relevant to their professional lives. Many respondents also said that they didn’t feel confident addressing issues related to climate change in their practice.

Climate change in the counseling office

Reese, a licensed professional counselor practicing in Bend, Oregon, believes that not knowing how to define — and, thus, recognize — climate concerns is part of counselors’ discomfort.

“What is climate change?” he asks. “Is it when you live in California and no longer have a home? … Is it a climate issue when a client is just talking about the general state of affairs and worrying about the world for their kids?”

Of course, there is also the matter of climate change being a polarizing topic, says Reese, an assistant professor of counseling and director of the EcoWellness Lab at Oregon State University-Cascades. When he is talking with clients about broader health and wellness and the topic of climate change comes up, sometimes they will tell him they think it is fake news. “What am I going to do?” Reese asks. “Am I going to impose my view? How do we find ways to introduce our wellness perspective without imposing?”

Reese’s practice is based on ecowellness, a model he co-developed with Jane Myers that revolves around a neurobiological relationship with nature. “The bridge here is, ‘Tell me about your relationship with nature,’” he says.

Reese says he does see a significant amount of ecoanxiety and fear of the unknown, especially among his adolescent clients. But they typically come in talking about depression.

Reese’s intake process includes questions about spirituality and life’s meaning and purpose. He asks clients about their outlook on the future, which is where their anxiety sometimes emerges. Questions about their relationship with nature often reveal the connection between that anxiety and their concerns about the climate.

If clients mention any angst about the environment, Reese asks whether they can unpack that a little more. He’ll follow up by asking questions about how a client spends their time outdoors, what their everyday access is to nature, where and how they feel most effective in nature, and whether they have any hobbies involving nature. He also encourages them to think about what role they can take on: “You mentioned being fearful about what your future is going to hold. What, if anything, can you do right now to address your concern about environmental crisis? … What is within your immediate grasp and control that you can do?”

Reese’s approach involves seeing what the individual’s broader landscape looks like and what their interests, passions and resources are. He urges his clients to get creative and often suggests that his adolescent clients take some kind of action at school, such as starting a recycling program. One of his adult clients took the action step of buying an electric bike and not driving his car as frequently to lessen his impact on the environment.

Reese also helps clients connect their hobbies with environmental action. For instance, if they like skateboarding, he’ll ask them what kind of impact they think that has on the environment. That may lead them to taking the action step of picking up trash around the skate park.

“It’s looking at what is the way we can increase self-efficacy in response to the environment so that it’s not abstract,” he says. “This is something I can engage in and learn and sustain this particular activity for myself and other people.”

Reese also asks clients to educate him about their activities. “For example, mountain biking is huge in Bend, but I don’t know anything about it. … What is the environmental impact? Oh, you don’t know either? Where can we find out?”

Climate change as social justice

ACA’s Climate Change Task Force notes that the resulting trauma from climate change has been and will continue to be experienced disproportionately. Black, Indigenous and people of color (and their communities), children, pregnant women, older adults, immigrants, individuals with limited English proficiency, those with disabilities, and those with preexisting and chronic medical conditions are all more likely to be affected by climate crisis and to have fewer resources to cope with its impact.

In September, the Gulf Coast will mark the 15th anniversary of Hurricane Katrina, one of the most powerful Atlantic storms on record. It wrought widespread devastation and flooding, including the overflow and eventual break of the levee system around New Orleans. As a result, 80 percent of the city was submerged underwater.

New Orleans and Katrina are important to the discussion of climate change as a social justice issue for a number of reasons, says Cirecie West-Olatunji, a past president of ACA who now lives and works in New Orleans. “Katrina was our first uber-disaster related to climate change,” she says. “It informed the world and was a global example of what was to come.”

West-Olatunji provided disaster mental health assistance in the aftermath of Katrina. “I could see the gaps,” she says. “The normal [disaster] response was not going to be sufficient.” Specifically, she recognized that the recovery period would be lengthy, the trauma and mental health challenges extensive, and the reconstruction resources unequally distributed.

Foreshadowing the 2017 tragedy of Hurricane Maria in Puerto Rico, the federal government’s response to Katrina was inadequate. It highlighted an essential barrier to recovery, namely that “whatever disparities exist prior to a disaster will be exacerbated post-disaster,” says West-Olatunji, an associate professor and director of the Center for Traumatic Stress Research at Xavier University of Louisiana.

Racial injustice, economic instability, and government funding for economic development that was distributed to certain communities and not to others were among the factors that magnified the physical and mental damage left behind by Katrina. And those factors continue to hinder recovery today. “Fifteen years later, and New Orleans is still in trauma mode,” West-Olatunji asserts.

There were multiple levee breaches, but only one adjacent neighborhood — the historically Black Lower Ninth Ward — was all but written off from the beginning of the recovery period, West-Olatunji says. Many of the residents owned their homes but faced multiple barriers to rebuilding. One of the most significant factors was discrimination in the distribution of Louisiana’s “Road Home” rebuilding funds. According to the Greater New Orleans Fair Housing Action Center (one of multiple plaintiffs in a lawsuit against the U.S. Department of Housing and Urban Development and the state of Louisiana), the program’s own data showed that Black residents were more likely than White residents to have their grants based on the much lower prestorm market value of their homes rather than on the actual cost of repair. Other displaced residents were unable to return and now cannot afford to pay their homeowners taxes, West-Olatunji says.

In the Lower Ninth, what’s left is an economic and food desert, with virtually no stores beyond a few mom and pops and only one school, she says. Developers have bought up properties, and instead of properly renovating them by gutting and bleaching the houses, in many cases they have simply repainted, leaving renters exposed to toxic mold.

In addition, much of what has been done to “rebuild” New Orleans has rendered it unlivable for those with low and modest incomes, West-Olatunji says. The city bulldozed public housing, and rent has skyrocketed. All of the city’s schools are now charter schools, which essentially makes them private schools that don’t answer to anyone other than their shareholders, she explains. “Kids are bussed all over the place … having to come out —unaccompanied — before daylight to find their way to school.”

New Orleans’ primary industry of tourism afforded a modest living to a significant number of residents for many years, West-Olatunji says. Pre-Katrina, that income could purchase a moderately priced house and even allow families to send children to state schools for higher education. Today, she says, the city is “assailed by outsiders and carpetbaggers who buy up properties. … We went from majority home ownership to rentals and Airbnbs.”

New Orleans is also a much whiter city now. Although most of the White residents who fled the city due to Katrina have returned, approximately 100,000 fewer Black people currently live in New Orleans than did before late August 2005.

West-Olatunji says there is a frequent refrain from the Black citizens who remained or returned: “I survived Katrina only to deal with the coronavirus and with the latest police brutality.”

“The trauma of Katrina was an overlay to existing and continuing stress and racial events,” she says. “It makes it really difficult to recover. … People are emotionally exhausted.”

Climate change should be of great importance to counselor practitioners, West-Olatunji says. “It’s influencing people’s behaviors and their possibility of choices. It narrows choices and creates barriers for living. Our job is to assist people in living abundantly. Climate change isn’t making that easy,” she says.

ACA member Edil Torres Rivera, a professor of Latinx studies and counseling at Wichita State University in Kansas, believes that climate change is still too frequently dismissed as a hoax. “Climate change is something that is real and … has implications for mental health,” he says, “particularly for populations like poor people, Indigenous people and people of color.”

Anyone who doubts that need only visit Rivera’s home island of Puerto Rico, where, three years after Hurricane Maria, people are still trying to recover. He says the urgent nature of the climate crisis is a primary reason that he joined ACA’s Climate Change Task Force.

In line with what happened in New Orleans after Hurricane Katrina, Hurricane Maria drove many people out of Puerto Rico, and those who remained faced multiple challenges, particularly around securing federal relief assistance and dealing with severe infrastructure deficits. Most critically, the island’s electrical grid was decimated, and it took approximately 11 months for power to be restored to everyone who lost it. But even now, Rivera says, it is still common for people to lose power for several hours whenever it rains. And this past January, a major earthquake left most of the island without power again for several days.

The trauma of Maria was compounded by the stress of the earthquake, which has been magnified even further by the coronavirus pandemic. “People are desperate,” Rivera says.

Many children in Puerto Rico are still terrified when it rains heavily and the wind rises, he continues. And since the earthquake, people are often hesitant about sleeping in their houses, so they stay in tents. This scenario will pose a major problem when a hurricane comes, Rivera says.

This past summer in Puerto Rico has been particularly hot, with some days reaching 103 degrees Fahrenheit. Rivera says this is higher than the norm when he was growing up and asserts that it again points to the effects of climate change. Typically, on hot days, people go to the beach to cool off. But the need to physically distance because of the pandemic has largely eliminated that option. Still, there are thos who, given the oppressive heat, would rather take their chances with possibly being exposed to the coronavirus. Another way that people cool off when it is hot is by having a beer, Rivera points out. He says that climate change has had a hand in sending both drinking and domestic violence rates through the roof for several years. The forced proximity of the pandemic is only exacerbating those trends, he adds.

Building resilience

Professional counselors “need to be involved and aware,” West-Olatunji says. “We can’t sit back and say that [climate change] has nothing to do with counseling.”

In fact, the counseling profession uses a holistic, ecosystemic perspective that looks at all the factors that influence behavior, she emphasizes. To take on climate change, counselors must broaden that model and consider structural interventions that target groups of people and focus on prevention. “Our discipline has always thought that prevention was at the core of wellness,” she points out.

West-Olatunji sees a great need for climate change literacy, noting that the people who most need knowledge about the climate crisis — because it is most likely to affect them either directly or indirectly — are also the least likely to have it. Vulnerable communities need to be given more information about how they can mitigate their risk and protect the health and safety of their citizens, she says.

Counselors can assist communities in building climate resilience by using their skills as facilitators to bring people together and help them work effectively as a group, says Mark Stauffer, a member of the ACA Climate Change Task Force. These groups don’t necessarily have to be focused specifically on climate change, he says. They could be formed to advocate for community needs, such as the right to clean water, or something more fun, such as establishing neighborhood gardens.

The essential aspect is to do the group work and to keep bringing people together, he says. “People coming together in times of need — we need to start practicing that now,” emphasizes Stauffer, the immediate past president of the Association for Humanistic Counseling, a division of ACA.

If counselors are personally concerned because their communities are not focused on climate change, Stauffer suggests they host a meeting of people who are interested in the topic. “See what people are thinking and where they want to go,” says Stauffer, a member of the core faculty in Walden University’s mental health counseling program. “It’s a process, but that’s the good part — connecting and building ongoing relationships. … People in the community need to get used to working together. The dialogue is just as important, if not more important, than the work.”

Stauffer thinks that counselors can play a key role in facilitating a new way of being in communities together. He believes that Western society has been living in a kind of empire culture, focused on what can be extracted. The mindset that started with Rome extracting treasures for itself from Europe and then Europe extracting treasures from its colonies has evolved into this sense that survival is about grasping and eking out a living by oneself, he says.

Stauffer says that our collective disaster survivor visual seems to be someone holding an AR-15 rifle in the air, surrounded by their supplies. “That’s not where we find joy,” he says. “Other cultures have found that surviving and being sustainable is something that we can do together.”

We need to find a way to be a part of the Earth in a generative way, Stauffer emphasizes. “The wild is not something to dominate and be afraid of,” he says.

Sturm, an associate professor and the director of counseling programs at James Madison University, urges counselors to get involved by finding out if their communities have climate resilience groups. Counselors who are unsure of where to start can bring themselves up to speed by using the U.S. Climate Resilience Toolkit (toolkit.climate.gov), a comprehensive resource that explores community vulnerabilities and climate resilience efforts.

Mental Health and Our Changing Climate: Impacts, Implications and Guidance, a 2017 report published by the American Psychological Association, Climate for Health and ecoAmerica, suggests several strategies for mental health professionals interested in promoting community well-being and helping to mitigate climate-related mental health distress. Among the strategies recommended:

  • Assess and expand community mental health infrastructure.
  • Reduce disparities, and pay attention to populations of concern.
  • Engage and train community members on how to respond.
  • Ensure distribution of resources, and augment with external supplies.
  • Have clear and frequent climate-mental health communication.

“Find out who is doing this in your area. Our voice has to be at the table to talk about trauma,” stresses Sturm, who is also currently earning her master’s degree in environmental advocacy. “Counselors think this is important, but they’re not doing it. … We’re not reaching out in our communities as a profession to be part of the discussion.”



ACA members: ACA’s free CE of the month for September is a video session titled “Climate Change and Mental Health: The Role of the Counselor.” See more here: aca.digitellinc.com/aca/


Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

  • Coping Skills for a Stressful World: A Workbook for Counselors and Clients by Michelle Muratori and Robert Haynes 
  • Disaster Mental Health Counseling: A Guide to Preparing and Responding, Fourth Edition, edited by Jane M. Webber and J. Barry Mascari
  • Introduction to Crisis and Trauma Counseling, edited by Thelma Duffey and Shane Haberstroh

Continuing Professional Development: Multicultural Products (aca.digitellinc.com/aca/specialties/158/view)

  • “Counseling Refugees: Addressing Trauma, Stress and Resilience” with Rachael D. Goodman
  • “Addressing Clients’ Experiences of Racism: A Model for Clinical Practice” with Scott Schaefle and Krista M. Malott

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources/)

  • Trauma and disaster
  • Family separation
  • Grief and loss


Laurie Meyers is a senior writer for Counseling Today. Contact her at lmeyers@counseling.org.


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

A climbable mountain: Quitting smoking and managing mental health

By Bethany Bray August 10, 2020

For people with a preexisting mental health condition, quitting smoking can seem like climbing two mountains at once.

Managing a mental health condition is a daily — sometimes moment-by-moment — challenge, and smoking is often used as a coping mechanism. Understandably, people with mental health conditions who smoke often fear that taking away that source of comfort could send them into a tailspin.

“That was the way I always seemed to manage my stress: Sit down, light a cigarette, and it would make my brain think, ‘It’s going to be OK.’ But in reality, it’s not,” says Rebecca M.* a Florida resident and participant in the Centers for Disease Control and Prevention (CDC)’s Tips from Former Smokers campaign who lives with depression.

Rebecca smoked her last cigarette in 2010. She quit smoking for good — and found balance in her life — with the support of a professional counselor. In hindsight, smoking only made her depression worse, Rebecca acknowledges.

For many people, mental health and smoking go hand-in-hand — you can’t fix one without addressing the other, she asserts.

“Wanting to be healthy, mentally, while smoking is impossible. After I quit, I was able to look at the world with a completely different mindset,” Rebecca says. “Smoking affects every aspect of your life — family relationships, work life, home life. It’s just a cloud. … When I see people who are struggling with mental health [while smoking], I have deep compassion for them. You want so desperately to get better, but with smoking, it’s like taking two steps forward and two steps back.”

In the family

Rebecca says she was “born into a family of smokers.” Growing up, all of her friends and family smoked, so it seemed natural for her to start smoking as a teenager.

She quit smoking for the first time in 2002. However, she started smoking again seven months later as she was going through a divorce and struggling with intense emotions and stress, she recalls.

Throughout this period, she met with several different counselors to help her manage her depression. She had an “aha!” moment in 2009 when her first grandchild was born; she knew then she wanted to quit smoking for good.

“When my oldest grandson was born, it made me stop and think about life in a different perspective. At that time, I reached out to find another counselor, to learn from past mistakes and learn a new way of life,” says Rebecca.

After smoking for more than three decades, she quit fully in 2010, roughly one year after setting the intention, seeking counseling, and going through “some intense self-reflection,” she says. “I was thinking about how I’m a grandmother now, and where do I want to be [in life]? I had a desperate desire to live a healthy lifestyle, and what can I do to get there?”

“Counseling gave me a sounding board, someone I could trust who could give me trusted answers,” Rebecca says.

Since quitting, she says, she has had to examine some friendships with close friends and even family members who continue to smoke. “If they’re not healthy for you, supportive of your healthy lifestyle, it’s important to make those changes as well,” she says. “It was a perspective shift: It’s the difference between being born into a life that you don’t get to choose and choosing the life that you want to live.”

The climb

Professional counselors can help clients meet life’s challenges with an approach based on leveraging the client’s existing strengths. For Rebecca, this included her intention to be a healthy example to her grandson. Practitioners have an arsenal of tools that can help clients make life changes and reach their goals, including smoking cessation.

Rebecca’s counselor helped her establish a self-care routine that includes exercise (she now runs regularly) and meditation. She has come to realize that she needed to exchange one unhealthy behavior, smoking, with a healthy behavior, exercise.

“Nothing will go well unless you take care of yourself first. Counseling taught me how to take care of myself first,” she says.

“[Quitting successfully] is about teaching people about the tools they need. When they are faced with a situation that may make them uncomfortable, or trigger a panic attack or need for a cigarette, they have to have [coping] tools ready and available. For me, it’s been exercise, staying grounded, and focusing on what I can control. I’m [continuing to] educate myself and learn as much as I can so that I can give myself the best self-care I can,” she says.

Most importantly, Rebecca’s counselor helped her accept that her depression, her tobacco dependency, and “all of this was not my fault,” she says.

“I don’t think I could have quit without counseling. I didn’t have the knowledge to do it on my own,” says Rebecca, who turned 63 this summer. “It’s essential to get someone [a mental health professional] who can help you walk this path to healthy living. It’s a path, a journey. It’s one step at a time, one day at a time, sometimes one moment at a time, but it’s empowering. It’s doable, and it feels amazing.”

Rebecca M. has exchanged one unhealthy behavior, smoking, with a healthy behavior, exercise. After smoking for more than three decades, she quit fully in 2010. Photo courtesy of the CDC’s Tips from Former Smokers campaign.

Ten years after quitting smoking, Rebecca’s mental health is good, but she acknowledges that she has to work at it every day. In addition to exercising regularly, she meditates often and tries to approach each day with an attitude of gratefulness, especially for things like a walk on the beach or video chats with her grandsons.

“I’m grateful for every one of those little moments I get,” she says. “It feels wonderful to climb that mountain. … It’s so empowering to be able to overcome tobacco use. There is a lot of life left [after cigarettes], even if you think there’s not.”

Counselors as allies

Professional counselors are particularly suited to help clients quit smoking because the profession has an array of tools focused on behavior modification. Instead of focusing on the health consequences of smoking — as a medical professional might — counselors can instead help clients focus on why they want to quit and how they can leverage their own strength to achieve that goal.

Practitioners also use a holistic perspective to help clients. For example, if a client turns to smoking in social situations because of anxiety, a counselor would help the client address the root cause, finding ways to cope with social anxiety. Similarly, if a client smokes to escape the negative thoughts that can be a constant companion of anxiety, depression, obsessive-compulsive disorder or other mental health conditions, a counselor can equip the individual with techniques to quiet their inner critic.

Read more about the many ways that professional counselor clinicians can support clients on their journeys in the Counseling Today article “What counselors can do to help clients stop smoking.”

In addition to counseling, Rebecca encourages people to use the plethora of tobacco cessation resources offered by the CDC.

“It’s OK to seek help,” she urges. “[Counselors and other professionals] want to see you succeed. You have it in you to succeed. That success is within you; you just have to learn to be kind to yourself and be loving to yourself. That, more than anything, was what I had to learn: to give myself the love that I give others.”




For support to quit smoking, including free coaching, a free quit plan, educational materials and referrals to local resources, call 1-800-QUIT-NOW (1-800-784-8669).




*Rebecca M.’s last name has been omitted for privacy reasons.




From Counseling Today: “What counselors can do to help clients stop smoking

Find a professional counselor in your local area through the link here: counseling.org/aca-community/learn-about-counseling/what-is-counseling/find-a-counselor

CDC’s Tips from Former Smokers campaign: cdc.gov/ tips

Rebecca M’s page: cdc.gov/tobacco/campaign/tips/stories/rebecca.html

CDC page on quitting smoking: cdc.gov/quit

Additional CDC resources on addressing tobacco use in individuals with behavioral health conditions:



Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.



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

Reformulating client well-being during an economic crisis

By Scott Gleeson July 13, 2020

Various forms of the same headline say it all: “The worst unemployment rate since the Great Depression.”

The U.S. Labor Department declared back in early May that 20.5 million people had abruptly lost their jobs as many businesses shut down or significantly altered their workforce operations during the coronavirus pandemic.

For mental health counselors, the COVID-19 crisis has prompted a plethora of alterations in conjunction with health-risk anxiety — from a major uptick in telehealth services to exacerbated symptoms for clients working from home extensively for the first time in their lives.

But what about adding the loss of a job or reduced wages on top of everything else? Quarantining takes on new meaning when a career is significantly throttled. The current unemployment rate is nearly double what it was during the Great Recession of 2007-2009.

“If you think about the college graduates of 2008, they’ve been in the workforce for a decade now, and they’re experiencing another major recession,” says Clewiston Challenger, a professor of educational psychology at the University of Connecticut. “This time, there could be a longer lasting effect on the job market. Your job is a major source of identity, so therapists can play a serious role in [helping clients find] that temporary identity without work.”

Clients also may have to adjust their mental health treatments based on changing insurance coverage from a lost job, and clinicians could find themselves adjusting their rates to accommodate financial burdens.

Of course, working clients have felt emotionally compromised too.

Ingrid Erickson, a licensed professional counselor and member of the American Counseling Association, works as a career counselor for Heritage Professional Associates in Chicago and as a leadership coach for BetterUp, a training firm that helps employees and companies bolster their work fulfillment and culture. She has noticed a common trend in which still-employed clients have felt an extra emotional weight over the past several months. As such, her therapeutic approach has been adjusted into “a mini treatment plan in the context of a larger one” — a compartmentalized plan with a sharpened focus on how the coronavirus pandemic is affecting each client, and then a broader scope that contains the client’s overriding goals pre-COVID.

“A common theme is that people have been running [over] capacity,” Erickson says. “Work provides a rhythm to our lives, and for some that normalcy was taken away amidst all the uncertainty of COVID. It’s created a situation where a lot of people who are working are pretty maxed out. There’s a lot of fear, and it can be difficult constantly trying to figure out what the new normal looks like. Emotionally, cognitively, it can be really draining.

“With a lot of clients, we’ve had a mini reassessment because COVID is uniquely impacting each person in different ways, whether it’s job insecurity, high-risk loved ones, interpersonal by living in tighter quarters … It’s important to take a step back and see how the added stress is playing a role in maybe bringing a lot of things to the [emotional] surface that normal life doesn’t. I find it helpful to acknowledge how the stress affects our work life. There’s this expectation of doing our lives as normal. Well, it’s not normal right now. We’re needing patience and compassion for ourselves.”

One way that normalcy can be hindered is in clients’ bank accounts. Gideon Litherland, a licensed clinical professional counselor at Veduta Consulting in Chicago and a Ph.D. candidate at Oregon State University researching supervision effectiveness, says broaching financial concerns with clients can become necessary, even if they are avoidant of such topics.

“This is the worst economic recession since the Great Depression,” Litherland says. “We can’t ignore or not talk about what clients may very well want to ignore. If the client does not want to tend to them, what are the fears in attending to those feelings? It becomes appropriate to say, ‘Hey, things are going on economically. How is this affecting you financially?’ It is clinically relevant to check in with a client about financial stress for their mental well-being. The experiences can be ‘Where’s my next paycheck coming from? Where could I live if I get kicked out of my apartment? What happens if I declare for bankruptcy?’ It’s entirely within our role and purview as clinicians to tend to a client’s basic needs, and [financial concerns] fall under that.”

Erickson says mindsets are different for every individual based on where their career trajectory was at before the coronavirus pandemic. She adds that the past several months have greatly influenced quarter-life and midlife assessments in reverse directions based on where clients were at in their identity development.

“The market is not great right now and very unpredictable, so a lot of people who were going through a job search put actively looking on the shelf for now,” she says. “Then there might be others who almost see this breaking period, whether furloughed or laid off or working from home, as an opportunity to rethink what they want their careers to look like. There’s a freedom to really reassess with creative thinking and problem-solving. When we do career thinking on a shot clock, we don’t do our best.”

A recent Wall Street Journal report found that the worst of the coronavirus shutdowns may be over. The uptick of air travel, hotel bookings and mortgage applications could signal a turn for the better economically in the U.S. However, those improvements could be tied to temporary factors, with emergency spending from Congress among key reasons for more temporary spending.

Erickson says that looking ahead to brighter days, while necessary, can be a double-edged sword. One thing she is coaching her clients with is the premise of separating short-term goals and emotions from long-term goals and emotions.

“Long-term hope and optimism with a vision for the future can be an anchor during times of stress,” she says. “Planning for the future has a value, but at the same time, fear and anxiety for the future can paralyze, so we run the risk of getting stuck worrying and rehashing over and over to where we’re emotionally suffering based on something that hasn’t actually even happened.

“I’ve found it can be helpful to shorten the time frames to avoid the emotional flooding and just … focus on making it through the next day and week. If you’re a small business owner, instead of asking, ‘How do I help my business survive?’ then focusing on immediate issues, what’s within your immediate control and then coming back later to focus on the months ahead.”

The gradual reopening of states also means that people who were working from home will be thrust back into their old routines and structures, albeit with a renewed outlook.

“There have been a lot of positives that have come from being away from the day-to-day,” Challenger says. “For many people who see their job as their identity, perhaps this crisis gave them a chance to focus on other facets of their life and look outside of their identities as employees. And now more than ever, companies are more comfortable with distance communication, so we might see some of these industries morphing into more Zoom meetings and working from home.”

Even as some people appear set for a return to normalcy in the short term, others are likely to experience lingering impacts from the economic crisis. For instance, college graduates who were poised to enter their respective professions after earning their degrees have instead been greeted by closed doors and blocked opportunities because of the coronavirus.

“COVID happened so abruptly,” Challenger says, “and now all of the sudden companies aren’t in a position to spend money anymore. So, that job a college graduate might’ve wanted is gone.”

In the long run though, Challenger adds, “The class of 2020 will be built on resilience.”

That notion of resiliency and a bounce-back effect is where Erickson sees the silver lining.

“Resiliency isn’t built in times where it’s easy,” she says. “We’ve been forced to live our lives without resources in ways we never had before. If anything, hopefully these times can show that we can make it and shows us what we can do.”



Related reading

See Counseling Today‘s August magazine for an in-depth feature on helping 2020 graduates navigate life after college amid the COVID-19 pandemic.


Scott Gleeson is a licensed professional counselor at DG Counseling in Downers Grove, Illinois, and Chicago. Contact him at scottmgleeson@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.