Tag Archives: cognitive behavioral therapy

Adapting CBT to meet clients’ needs

By Lisa R. Rhodes July 13, 2023

A woman facing the ocean with her eye closed and taking a deep breath

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Cognitive behavior therapy (CBT) is one of the most widely used forms of psychotherapy in the mental health professions. It is also the most empirically tested modality, with more than 2,000 evidence-based studies, according to the Beck Institute for Cognitive Therapy and Research, a nonprofit organization (co-founded by the late Dr. Aaron Beck, the psychiatrist who developed CBT) that works to advance CBT and train mental health practitioners and organizations around the world.

This short-term, highly structured form of therapy helps clients pinpoint and examine negative thoughts to reframe their thinking so they can develop a pragmatic view of difficult situations and learn to better manage them. CBT can be used to treat a wide range of mental health conditions, including anger, eating disorders, stress and attention-deficit/hyperactivity disorder.

Vanessa Teixeira, a licensed mental health counselor who specializes in trauma-focused CBT (TF-CBT), says one advantage to using CBT with clients is that it is “simple, concrete and makes sense.” Clients learn “why they are thinking what they are thinking, feeling what they are feeling and behaving how they are behaving,” Teixeira explains. “Once they have that knowledge, they can choose to actively participate in their treatment by making certain simple and concrete changes to their thinking and behavior.”

Positive therapeutic outcomes

CBT is most commonly used to treat anxiety and depression. Janeé Steele, a licensed professional counselor (LPC) and certified CBT therapist, says CBT can help anxious and depressed clients decrease their psychological distress and improve their ability to cope with life stressors. This can happen by teaching clients how to use CBT skills such as identifying and reappraising maladaptive thoughts and beliefs.

Steele, author of the forthcoming book Racism and African American Mental Health: Using Cognitive Behavior Therapy to Empower Healing, says clients can also learn to apply CBT skills such as behavioral activation to positively affect their mood by increasing the amount of time they spend engaged in activities that provide a sense of pleasure or accomplishment. By teaching clients mindfulness strategies, such as deep breathing and relaxation techniques, counselors can help them with emotion regulation.

Some variations have been developed to tailor CBT to better meet the needs of certain mental health issues. For example, TF-CBT was developed in the 1990s to address the needs of children who had experienced sexual abuse, but today the scope has broadened, and clinicians can use TF-CBT to help children and adolescents recovering from all types of trauma. Christa Butler, an LPC who is certified in TF-CBT, says TF-CBT can help reduce the symptoms of trauma in children and teens and enhance their inner sense of safety. The modality, which includes parents and caregivers in the therapeutic process, is also effective in emotion regulation and building cognitive and social awareness skills, she adds.

Although CBT is an effective clinical approach for many mental health disorders, some mental health professionals argue that some of the techniques do not best address the needs of all clients, particularly those from marginalized communities. Practicing counselors are making cultural adaptations to the modality to better serve clients of color, and they are finding creative ways to combine other clinical techniques with CBT and TF-CBT to help adapt and modernize this approach to better address clients’ individual needs.

“The more we adapt CBT to suit the individualized needs of our clients, the more effective the treatment outcomes will be,” Teixeira says. “Any counseling theory and technique should first and foremost focus on the client as a unique individual and how counseling treatment can be best modified to produce successful results.”

Cultural adaptations

Steele, owner of Kalamazoo Cognitive and Behavioral Therapy PLLC, stresses the need for clinicians to culturally adapt CBT to better meet the needs of clients of color. Like all therapeutic approaches, CBT can’t be separated from the cultural context in which it was developed, Steele says. CBT “was developed with Eurocentric, individualistic assumptions that are not always suitable for clients from more collectivistic cultural groups,” she notes. And this may cause some clinicians to inadvertently overlook the environmental influences in a client’s life, she adds.

This can mean that there is the potential for clinicians who use CBT to “blame clients for problems that are primarily environmentally based, which can lead to an invalidation of their experiences,” Steele notes.

This can lead to negative outcomes. For example, she says that if the perspective and lived experience of people from marginalized backgrounds are not considered in therapy, they may decide to end treatment prematurely or they may experience a worsening of mental health symptoms.

Teixeira, an assistant professor in the Department of Counseling at Nova Southeastern University in Fort Lauderdale, Florida, also advises counselors to make cultural adaptations to CBT when working with clients who are vulnerable, underprivileged, disadvantaged or facing systemic discrimination. The adaptations should be made “to acknowledge that certain populations are not always in control of their environment and [that] certain groups of people have a major unfair disadvantage that directly impacts their thoughts, feelings and behaviors,” she says.

For clients who are dealing with racial trauma, Steele says cultural adaptations to CBT such as psychoeducation and culturally adapted cognitive restructuring can help them reduce their mental distress and build coping skills that foster their resilience in adverse situations. Steele discusses how to use these two cultural adaptations to treat a hypothetical client: a Black man in his mid-40s, who was the only Black male volunteer in a predominantly white organization. The client was having difficulty managing feelings of anxiety about fitting in at the organization. She says the client reported feeling worried and nervous when he tried to contribute his ideas in staff meetings, and he also experienced feeling dismissed and insecure when he was not considered for community assignments.

Steele found that using enhanced psychoeducation helped the client understand how social anxiety, which was the client’s presenting concern, works. For example, she talked to him about “stereotype threat,” a fear that people of color have about aligning themselves with negative stereotypes about their racial group, and how this threat may have contributed to his unease.

In this case example, the client felt an internal pressure to try to prove that he did not conform to the negative stereotype of Black men as inarticulate and only able to achieve in athletics, Steele explains. “This contributed to the self-focused attention aspect of his social anxiety and worsened the client’s performance, as his attention was often directed to perceived deficits in his use of language and [his] ability to communicate rather than the task at hand,” she notes, which often caused him to appear as though he could not concentrate or was forgetful.

“Intentionally situating problems in their cultural context in this way is omitted from traditional CBT,” Steele says. But the cultural context piece is critical in cases such as this one. Discussing stereotype threat in counseling allowed the client to better situate his problem within the cultural context and validate his lived experience as a racial being, she says.

Steele also adjusted how she approached cognitive restructuring with this client. “Traditionally, cognitive restructuring focuses on teaching clients to examine the rationality of their thinking through techniques such as Socratic questioning,” she notes. “Questioning clients’ experiences with race-related concerns, however, can be invalidating and may exacerbate their symptoms.”

Instead, she used Socratic questioning to examine the client’s negative self-thought and account for the impact of racial oppression in his life. “Adapted cognitive restructuring focuses on validating the painful emotions that arise in the face of these experiences, acknowledging that we live in a society where these painful experiences occur, and challenging negative thoughts about self that occur in response to these experiences rather than the experiences themselves,” she explains.

Working with this client, Steele asked questions to determine the thoughts he had that contributed to his anxiety and nervousness during staff meetings, such as “I sound too Black” or “I’m never going to fit in here.” She continued using Socratic questioning and asked culturally framed questions to help the client recognize and examine stereotypes that contributed to his negative thoughts about his self-worth and competence.

Using traditional CBT questioning, counselors may ask this client, “What evidence do you have to support the idea that you won’t fit in at work?” or “What’s another way to view the situation?” But this type of questioning can be insensitive to the client’s life and cultural context, and it could be perceived as a microaggression because it often requires people of color to prove their experiences with race, Steele says. Instead, she advises counselors to ask questions that consider the cultural context. For example, clinicians could ask, “What are the stereotypes that relate to being a Black man?” “When did you first encounter these stereotypes?” or “How do these stereotypes influence how you feel and what you think about the way people may perceive you?”

Steele reminds counselors to be careful when using CBT and avoid asking questions that might suggest the client’s discomfort about their experience is unreasonable or abnormal. “Microaggressions and questions that invalidate the client’s experience with race, ethnicity or culture can lead to ruptures in the therapeutic relationship or even worsen the client’s symptoms,” she notes. “They can also reinforce stigma associated with [the] receipt of mental health services and the perception that counseling is only for certain racial groups.”

Creative clinical approaches

When applying CBT and TF-CBT to other mental health issues, such as panic and trauma, the counselors interviewed for this article recommend incorporating creative techniques alongside these therapeutic approaches. Teixeira says using creative, individualized and unique CBT interventions such as spontaneous journal writing, gardening, coloring mandalas, and creating video blogs, vision boards and music playlists can help teach adults how to process and better manage difficult thoughts and emotions.

Grounding exercises are another creative CBT technique that Teixeira recommends counselors use with adult clients. These exercises use the five senses to help the client refocus their physical and emotional attention when they feel anxious, for example. “It allows the mind and body to take a break from the anxiety and panic it is currently experiencing by shifting the focus to more neutral and/or positive items that can temporarily change the client’s thoughts and feelings,” she explains.

Teixeira says counselors can ask clients to create a “grounding box” that can be used when they are experiencing panic or anxiety. The box should be filled with items that engage the five senses and provide the client comfort, she says. For example, the box could contain the following items:

  • A ball that can be squeezed
  • A beach shell that allows the client to hear the ocean
  • A dried lavender flower to smell
  • A pack of gum that the client can taste
  • A funny or relaxing picture that the client can look at

Teixeira says this technique can be adapted to use with children and adolescents by having them fill it with items that bring them comfort, such as a small toy, fidget spinner, scented play dough, lollipops or a whistle.

Butler, a professional counseling issues specialist at the American Counseling Association and a registered play therapist supervisor, says TF-CBT can help children and teens process their thoughts and feelings about traumatic experiences, while providing them with a safe container to explore the impact of their experiences. She recommends counselors pair this approach with play therapy or play-based expressive therapy approaches, such as sand tray interventions and art-based activities.

The trauma narration process in TF-CBT can be “emotionally overwhelming” for children and teens who may be sharing the details of their trauma for the first time in therapy, Butler adds. So she advises counselors to incorporate age-appropriate games, such as flashcards, and expressive outlets, such as painting, to help make the therapeutic process more engaging while also providing a safe distance for clients to project their thoughts, feelings and emotions about lived traumatic experiences.

Counselors can also pair mindfulness-based techniques with TF-CBT. Butler and Teixeira suggest counselors use the activity of blowing bubbles to teach children about mindfulness. Clinicians can ask clients to breathe in and then slowly exhale as they blow the bubbles, which relaxes their body and mind.

When using games and art-based interventions, counselors must be sure to use tools that are culturally inclusive, Butler adds. This includes selecting miniatures, toys, dolls and images used in making collages that are representative of diversity and intersectionality. For example, counselors who use play therapy or work with children need to have a full spectrum of colors in their crayons, markers and pencils so clients can depict all different shades and tones of skin color in their drawings, Butler says. Counselors should also look for culturally diverse miniatures for use in sand tray therapy, she adds.

A staple approach

The counselors interviewed for this article say that CBT’s ability to treat a wide range of mental health disorders and its adaptability to fit clients’ needs are two reasons why the modality is likely to remain a staple in mental health. Teixeira also encourages new counselors not only to develop a mastery in understanding the main concepts of CBT, but also to engage in additional training for using CBT with special and vulnerable populations, which is important for the ethical use of the modality, she says.

Steele agrees that CBT “will continue to be the gold standard in behavioral care.” The emphasis on the empirical validation of treatments continues to be a priority within the profession, she says, “especially as it relates to increasing validation of the approach among culturally diverse groups.”


For more ways to adapt cognitive behavior therapy (CBT) and cultivate an awareness for cultural diversity, check out the following resources:

Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@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.

Working with clients who are angry at God

By LaVerne Hanes Collins May 11, 2021

What, exactly, are we to expect from God? What is God’s role in the human experience? What’s a counselor to do when a client is angry at God?  

In 2020, 48% of Americans surveyed by Gallup said that religion was “very important” in their life, and an additional 25% said that religion was “fairly important.” Only 27% said that religion was “not very important” in their life. 

Among the 73% who answered that religion was very important or fairly important to them, there are undoubtedly a variety of beliefs about what a person should expect, or not expect, from God. Those deeply personal expectations can be dynamic as they are shaped throughout the life span, evolving and changing over time. 

As a licensed clinical mental health counselor trained in Christian thought and faith-based counseling approaches, I’m used to my clients coming to my office with a range of definitions for faith, religion and spirituality. They come with varied beliefs and assumptions about God. These have typically been shaped by family tradition, religious institutions, influential friends and thought leaders, their own singular experiences and interpretations, or by any combination of these factors.  

I recognized early in my career that people sometimes become angry at God when there is a discrepancy between their expectations and their experiences. I was already an ordained minister when I went into counseling, but I knew that I needed more training to be effective with faith-based concerns. So, after receiving my master’s degree in community counseling, I earned a doctorate in Christian counseling so that I could help people work through issues of faith and spirituality. 

Clients usually come to me because of something painful and unexpected: any kind of loss; a misfortune; an untimely death; a miscarriage; a broken marriage; a sick child; an economic or job-related crisis; an abuse, assault or robbery; a health crisis; an injustice; a natural disaster; or any other traumatic event you can imagine. Clients suddenly feel that their situation — or even their life — bears the imprint of a rubber stamp: “Goodness Denied!” It brings about an unnerving discrepancy between the individual’s expectation of a loving God and their lived reality. 

Why it’s hard to talk about anger at God

When a person experiences a crisis or traumatic event, the initial feelings — sadness, anger, disappointment, fear — are typically about the event itself. Other powerful emotions often reflect existential questions about God’s role in their situation. Was God present (abandonment)? Why was this allowed to happen (confusion)? Then there are questions about their own feelings. Is it OK to be mad at God? Are they allowed to feel this way?

Depending upon a person’s beliefs, the thought of being angry at God, an all-powerful transcendent being, can seem rather taboo. The very mention of God suggests authority — an ultimate moral authority. So, to be angry at God can seem irreverent or sacrilegious. It may be an anger that is easy to feel but terrifying to verbalize.

Clients with a spiritual or religious worldview may come to therapy afraid of being judged for those beliefs in the same way that they fear being judged by factors such as race/ethnicity, economic status or sexual orientation. It is a sensitive area because spiritual or religious values reflect the principles upon which a person makes decisions that govern their life. Those values reflect a moral compass that provides direction for one’s views, perceptions and choices. Counselors are bound by our professional codes of ethics to respect the diversity of religious and spiritual positions held by clients. We are to regard those spiritual beliefs as elements of cultural diversity, requiring a commitment to cultural awareness and sensitivity in our counseling work.  

The painful questions

When crisis strikes, a person may tend to question God’s goodness. “God is good. What happened to me is not.” Did God cause the crisis? Why didn’t God prevent it? Why is God always loving to everyone but me?  

A 2010 Baylor University Religion Survey project suggested that a person’s expectations of God are determined by their answers to two questions. First, is God involved or uninvolved in human affairs? Second, is God benevolent and merciful toward humanity, or is God judgmental and critical toward humanity? The model that came out of this study suggested that the aspect of religion that is most relevant to a person’s mental health is the nature of their relationship with God. It’s a matter of how people see God relating to them.

Baylor University’s Paul Froese and Christopher Bader described this in their 2010 book, America’s Four Gods: What We Say About God — And What That Says About Us. They asserted that regardless of our religious tradition (or lack thereof), Americans worship four distinct types of God. First, nearly all Americans believe that God is loving. But there are significant differences in the way people view God’s involvement and God’s judgment in the world. The study said that some Americans (31%) believe in an authoritative God who is more engaged and more judgmental. Others (24%) believe in a benevolent God who is more engaged and less judgmental. There are also those (16%) who believe in a critical God who is less engaged and more judgmental. The last group represents people (24%) who believe in a distant God who is less engaged and less judgmental. 

The Baylor model has provided me with a useful paradigm for case conceptualization. When I see clients who are angry at God, it is typically because of a discrepancy between their experience and their expectation. The characteristics that they ascribe to God no longer make sense. On the other hand, when their situation is consistent with the extent to which they believe God engages and judges the world, there is less tendency for cognitive discrepancy and anger at God. 

In therapy, I give the client space to vent their anger. The way the client explains why they’re angry at God provides insight about which profile they ascribe to God. That profile essentially forms the underlying beliefs that get explored in cognitive behavior therapy (CBT).  

When the person’s complaint against God stems from something that God failed to do or failed to provide, it suggests that the person expects God to be involved in and benevolent toward the situation. They may be angry at God for neglecting to provide protection from a tragedy, for denying something that they expected to receive or for failing to heal a disease. This is inconsistent with their expectation of a benevolent God who is kind, merciful, compassionate and protective. A major cognitive discrepancy then exists.

Although people generally perceive God to be loving, some clients may question why God seems to not dole out punishment or judgment for wrongdoing. These clients may describe dismay because they expected some execution of justice, yet it seems that God is allowing someone to “get away with” something. This departs from their expectation of an authoritative God who is engaged and who also judges and punishes sin without delay. “Why did God not bring that party to justice? Why was I unjustly denied while someone else was unjustly allowed?” they ask.

Clients who believe in a distant God will see God as being uninvolved with today’s world. They may believe that God created the world through a kind of cosmic force, but they see God as now being removed from that world and simply observing from afar. For them, God set the world in motion but has remained unknowable and perhaps even mysterious. This belief suggests that God may not be paying much attention to mere mortals. When tragedy comes — to good people or to evil people — there are absolutely no answers from God. God exists, but not for the sake of involvement. 

Clients who see themselves as having created their problems may expect to go through life hopelessly. They often believe that a critical God allows punitive misfortune and is not engaged in the business of bettering human conditions for those who have morally failed. This leads to low expectations about improvement in their situation. 

So, while religious activities such as prayer and regular attendance at services have been the traditional measures of religiosity in Western culture, Froese and Bader suggest that those behaviors have little effect on someone’s reported mental health. The study found that people who believe their troubles are the result of God exacting judgment because of sin have higher levels of anxiety, paranoia and compulsion than those who believe in a caring, engaged God who will help them cope with life’s challenges.

When counselors understand a client’s image of God, they have an opportunity to explore and invite reflection upon that person’s internal beliefs and thoughts. That can be helpful to counselors in health care and disaster response because many painful issues give rise to the question of “Why me?” The most effective way of answering that question is from within that person’s view of or belief in God, not by trying to change that person’s belief (unless the person is ready to challenge their own belief system).  

A cognitive behavioral response

CBT involves the exploration of underlying beliefs that form the foundation of a person’s thoughts, feelings and subsequent actions. The Baylor study’s typologies of God in America offer four different cognitive beliefs that clients may subscribe to. Cognitive discrepancy is present when two cognitions are experienced as conflicting. One example comes from a client who said, “God is good and brings good things to our lives, but what happened in my life is not good.” Another client grieving a series of miscarriages said, “The womb is for giving life; my womb only gives death.” These statements reflect emotionally painful discrepancies between these clients’ expectations and their experiences. 

People will naturally seek information that is congruent with their beliefs. However, when their emotional pain becomes too great, they will also try to engage in dissonance reduction by avoiding information that is incongruent with the belief they want to hold on to. When they cannot find a way to retain the belief, they may abandon their faith completely. 

An alternative approach: Creation-Fall-Redemption

In my practice, clients who come from Judeo-Christian traditions have found the following reframe particularly helpful for taking God out of the four boxes. In this way of looking at problems, clients can consider and develop a theology of suffering that normalizes their pain and gives them an alternative lens for their situation.  

Creation: The sacred texts of Judaism and Christianity begin with the story of how God created the earth, everything in it, and humanity. At each stage of Creation, God paused and said it was good. God gave permissions and parameters to the man (Adam) and woman (Eve). As long as they followed God’s plan, life was blissful. They were warned, however, that operating outside of God’s permissions and healthy parameters would start a cascade of difficulties throughout the whole earth and throughout all generations. This disobedience would add the knowledge of evil to the good things they already knew and disrupt the harmony of the entire creation. 

The Fall: The second stage in the human experience was an unfortunate one, as Adam and Eve both went beyond the limitations that had been set. This is commonly referred to as “the Fall” (of humanity). Artists often portray this event as the eating of an apple, but that seems to just be artistic interpretation. The important thing to realize is that the consequences of this event introduced into the world three sources of problems: moral evil, natural evil and human limitation.

Each of these represents a different source of pain that all of humanity is unfortunately destined to experience because of the introduction of evil into the world. Moral evil includes all of the selfish human choices that bring harm to others or to our world: violence, greed, assaults, etc. Natural evil includes those things that bring destruction and devastation beyond our control: health issues such as sickness, disease, infertility and miscarriages, and atmospheric conditions such as destructive weather, earthquakes, pestilence and accidents. The third category, human limitation, includes restrictions on our capabilities, which we call weaknesses, and our now-limited life spans, which we call death. 

Clients benefit from being able to categorize their problems. They long to know how to interpret them, and often, God has seemed like the only one to blame. Instead, clients can choose at least one of these three categories for every problem known to humanity. If they subscribe to a Judeo-Christian belief system, they find the answer in the very beginning of the history of humanity, in the context of a faith that they already believe in. 

Redemption: Can something good come out of this? Is there any comfort to be found in this pain? If the effects of the Fall cannot be immediately reversed, where is hope? For clients looking for an answer within the Judeo-Christian tradition, redemption is found in one’s faith — in the belief that God will not leave the world forever in the condition that sin left it in through the Fall. 

There are different symbols for redemption that depend on the faith belief system of the client. I often ask clients what redemption means for them in the context of their faith. Some find comfort in knowing that God’s love is available to them no matter how painful their situation and that God is lovingly walking beside them through the worst of times. Others may speak of present opportunities to turn their painful experience into something positive by helping others. Many Christians will speak of Jesus’ resurrection. Still others describe a sense of eternal justice that is yet to be understood here on earth. 

In this way, God is seen as being with them in their pain but not as the cause of their pain. The key point is that clients examine their discrepant beliefs and find a way to reframe their tragedy or pain into beliefs that empower them with resilience. With that, they can more easily resolve the cognitive discrepancy without letting go of the faith that they hold dear.

The cognitive behavioral inquiry

The process of exploring which of the four God types the person subscribes to and then introducing a Creation-Fall-Redemption alternative involves a basic cognitive behavioral approach. Here are some key talking points for the cognitive behavioral process.

Identification of beliefs

  • Identify the spoken and unspoken beliefs about life, suffering, God, people, etc.
  • Explore where those beliefs came from.  
  • Discuss the expectations that are held in those beliefs.

Thought reconciliation

  • Identify the client’s thoughts about this particular situation.  
  • Explore any incongruence, inconsistencies or dissonance between beliefs and thoughts.
  • Identify the form of evil in the client’s situation: moral evil, natural evil or human limitation.

Emotion management

  • Name the emotions. (What’s the individual’s history with that emotion?)
  • Determine if there is a need for forgiveness of self or others. If so, ask the client to choose whether they’d like to act upon that.

Behavioral adjustments

  • Encourage the client to determine how to use the anger or other emotions constructively.

Sample questions for cognitive behavioral processing

Socratic questioning is a valuable tool in CBT. This method is especially useful with the sensitive issues of spirituality and religion because counselors must approach this topic without judgment about the client’s beliefs or values. The best questions are open-ended, focused, concise and neutral. Questions such as these can be used at any appropriate point in the process described above.

  • What would change for you if you could see God being as angry about this injustice as you are?
  • How would it be for you if you knew God was as saddened by your loss as you are?
  • What would you like the fruit of your pain to be?
  • What if you didn’t need to figure out how you’re supposed to feel or supposed to act?
  • What if your situation is a result of a fallen world rather than a fallen God?

Diagnosis and treatment planning

What about a billable diagnosis? What about measurable treatment goals? Counselors often avoid religious and spiritual discussions in therapy because they need a billable clinical diagnosis for third-party payers. Rarely, however, does a client initially state their presenting concern as anger at God. That’s mainly because it feels taboo and unacceptable to be angry at a Supreme Being. Clients do present with symptoms of depressive disorders, generalized anxiety disorder, adjustment disorder and trauma-related disorders. The billable diagnosis is there. 

Specific and measurable goals are found in reducing the frequency and severity of the diagnostic symptoms associated with the disorders. This might include a specific reduction in the number of days when particular symptoms cause clinically significant distress or impairment in functioning. It might include a specific reduction in undesirable self-medicating behaviors each week or a reported improvement in problematic sleep patterns. As the person resolves the religious- or spiritually related anger, issues such as these will often improve. The success in this kind of goal setting is in getting a baseline severity measure and then measuring symptom improvement over time. 

Issues of abuse are a clear exception to this CBT approach. When a client’s history involves any form of victimization such as spiritual manipulation or sexual abuse, the counselor must exercise extreme caution. In these cases, trauma-informed care and trauma-specific interventions are more appropriate than CBT interventions. 


Clients of deep spiritual and religious faith may come to counseling at a major life crossroads. The perception of God denying goodness can lead to a real crisis of faith. The tendency to typecast God into one of four frameworks leaves people struggling to make sense of a situation that creates a discrepancy between their expectations and their experience. As counselors respond in ways that help clients clarify their theology of suffering, we can also help them cope effectively with present and future problems.


LaVerne Hanes Collins is a licensed clinical mental health counselor, licensed professional counselor and national certified counselor. She is the owner of New Seasons Counseling, Training and Consulting LLC, where she develops in-person and virtual continuing education (CE) training for licensed counselors on issues of race, faith, culture and trauma. Her web-based CE training on CBT for clients who are angry at God is available at: http://bit.ly/3tqfMGu. Contact her at DrCollins@NewSeasons.training.

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.


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.

Bringing evidence-based processes into the therapy room

By Boyd Eustace and John Donahue June 5, 2019

By way of introducing ourselves as the co-authors of this article and providing a little context for what follows, John Donahue is a clinical psychologist, an assistant professor at the University of Baltimore, and a practicing psychotherapist. Boyd Eustace is a licensed counselor and a lead therapist at a hospital-based outpatient mental health clinic in Baltimore, in addition to maintaining a private counseling practice in the city. The University of Baltimore’s graduate program in counseling psychology and the outpatient clinic in which Boyd works partner in the training and professional development of the university’s graduate students. Colleagues on both sides of this partnership share an interest in fostering collaboration between graduate-level training programs and clinicians in practice settings. A primary focus of the partnership is bridging the gap between academia and clinical practice.

At this point, it has been well-established that a science–practice gap exists in the field of mental health. In 1996, in an article for BMJ, David L. Sackett and colleagues suggested that evidence-based practice reflects clinical decision-making on the basis of three components:

1) Research evidence

2) Clinical expertise and judgment

3) Client values, preferences and characteristics

Later, the American Psychological Association adopted this “three-legged stool” approach when it defined evidence-based practice in psychology as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.”

One way the separation between science and practice can be witnessed is in the varying weights that mental health practitioners tend to apply to the different legs of the evidence-based practice stool. For example, research has found that prior clinical experiences exert the strongest influence on treatment decisions. Additionally, mental health practitioners almost universally report incorporating client expectations and values into treatment planning and strive to establish strong working alliances with their clients. However, when it comes to the first leg of the stool, clinicians have frequently reported hesitancies about factoring in empirical research findings when assessing and treating their clients. This contrast may in part stem from negative perceptions toward empirically supported treatments (ESTs) (see Michael E. Addis et al., 1999) and from confusion among community mental health providers concerning the differences between ESTs and evidence-based practice (see Michelle A. DiMeo et al., 2012).

The EST movement has expanded our understanding of many psychotherapy protocols that are efficacious in the treatment of specific diagnostic categories. With that said, ESTs certainly have not become a panacea for treating distinct disorders, and a few serious issues have hampered widespread dissemination of research-backed treatments to community-based clinics. Among these issues are concerns that:

  • Efficacy studies generally include samples that are not representative of the modal, multiproblem patient/client with several comorbidities
  • Treatment manuals result in rigid and mechanistic applications of psychotherapy
  • Studies often fail to attend to mechanisms of change that underlie variance in outcomes
  • Primary outcomes of randomized controlled trials (i.e., symptom reduction) are not necessarily the primary outcomes of interest for patients/clients in the community

In addition to these stated concerns about treatment protocols, there is substantial evidence that the targets of ESTs — individual Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses — are themselves invalid. Since the DSM introduced the categorical model of psychopathology in 1980, research has generally supported the conclusion that the diagnostic system is plagued by comorbidity, heterogeneity of symptoms within diagnoses, lack of adequate symptom coverage (resulting in excessive “not otherwise specified” diagnoses), and diagnostic thresholds that appear quite arbitrary.

Given these findings, the National Institute of Mental Health has stated that it is moving away from DSM-based diagnoses as its outcome of interest and has instead introduced the Research Domain Criteria (RDoC) initiative, which articulates a group of putative mechanisms of psychopathology that can be studied at varying levels of analysis. However, the RDoC approach, which is still in its nascent stages, has been critiqued for its emphasis on the biological level of analysis. It is currently a framework for research rather than a classification system that demonstrates clinical utility.

Fostering evidence-based care in light of obstacles

Although ESTs have been helpful in furthering scientifically informed mental health practice, the preceding section demonstrates that they possess numerous limitations and do not represent the compendium of effective counseling methods or stand for our full understanding of evidence-based practice in clinical settings. They have also too often contributed to the proliferation and endorsement of brand-name treatment approaches and trademark interventions, creating further divisions between orientations and increasing resistance to evidence-based practice. Moving beyond the era of prescriptive treatment protocols for specific disorders may therefore be helpful in expanding the use of evidence-based practice in the clinic.

In this spirit, we embraced a recent book by Steven Hayes and Stefan Hofmann titled Process-Based CBT: The Science and Core Clinical Competencies of Cognitive Behavioral Therapy. Rather than outline yet another protocol, or describe the techniques important for x disorder, the purpose of this text is to describe the “core processes that are common to many empirically supported treatments,” regardless of tribal theoretical identities and disregarding the confines of illusory diagnostic boundaries. Because of this approach, we thought it might be a particularly valuable vehicle in disseminating evidence-based practice into the community clinic.

As a lead therapist at this particular outpatient clinic, Boyd organized five monthly seminars focused on evidence-based practice and process-based cognitive behavior therapy (CBT) during the summer and fall of 2018 with the hospital’s mental health staff. We (John and Boyd) collaborated on curriculum content and co-led the seminars. The goals of these meetings were to increase the participants’ overall knowledge related to clinical research, broaden their understanding of evidence-based decision-making, and help identify various ways for them to incorporate science into their everyday practice. Participants included licensed practitioners, students-in-training and clinical supervisors.

Each monthly seminar was approximately 90 minutes in length, was offered around midday during a period that would conflict less with client sessions, and focused on specific chapters and topics from Process-Based CBT. Specifically, topics included:

1) The history of ESTs and problems with the “protocols for syndromes” approach

2) Evidence-based practice and some drawbacks with over-reliance on clinical judgment

3) Benefits and obstacles implementing ESTs in the clinic

4) Core cognitive, behavioral and emotion regulatory processes

5) Cognitive restructuring, cognitive defusion, exposure and psychological acceptance

Each seminar included brief didactic presentations on agenda items followed by group discussion. In essence, we did not want to teach another protocol. Instead, we sought to engage the mental health team in a discussion about specific processes and techniques that are empirically validated.

What did we learn?

At the conclusion of the seminar series, team members were offered an opportunity to complete a questionnaire designed to provide feedback concerning the pertinence and usefulness of the information presented in the educational workshops. The questionnaire included three items rated on a Likert scale ranging from strongly disagree to strongly agree, plus one open-ended question. Eight of 12 practitioners chose to complete the questionnaire. All of these practitioners were either licensed clinical social workers or licensed professional counselors with prior clinical experience ranging from four to 18 years. General outcomes were as follows:

  • All practitioners either agreed or strongly agreed that the seminars provided information that might help them integrate science into their everyday practice in the clinic.
  • Most practitioners either agreed or strongly agreed that the seminars broadened their understanding of counseling outcome studies, ESTs, randomized controlled trials, and some of the problems related to treatment-construct validity and generalizing findings to practice settings. (Two participants responded that they were undecided.)
  • All practitioners either agreed or strongly agreed that the seminars delineated the advantages and challenges of using evidence base to inform
    clinical decisions.

Additionally, practitioners were asked about the ways in which the seminar modified their views on evidence-based practice. Illustrative of the possible benefits of this program, several practitioners noted that evidence-based practice is beneficial because it helps clinicians select interventions that have been proved to work. One respondent wrote, “The seminar made me aware of the disconnect between research and practice … that we are still trying to find ways to connect research and practice.” Another wrote, “It is important to also consider clients’ preferences and values along with research.”

In conducting this seminar, we also arrived at some revelations. One is that, sometimes, clinicians are regularly using evidence-based techniques but are unaware that they are doing so. For example, in our discussion on exposure procedures, one clinician noted that she did not conduct exposure therapy, and this statement was then endorsed by several other members of the group. However, when the clinicians were prompted to consider ways in which their work with clients facilitated emotional willingness and tolerance of difficult experiences, it became clear that this procedure was a significant part of their practice. When the emphasis is on protocols, we may be more inclined to say, “I don’t do that.” But when the conversation shifts to processes, we can more easily notice the instances in which specific empirically supported procedures are useful, thus bringing additional intentionality to the use of these techniques.

In connection to our own work, this seminar series has reminded us of the importance of assessing and monitoring changes in processes, not just changes in outcomes. When we track a process in session and use procedures in the service of modifying that process, we should also close the loop and assess this change (or lack thereof). This can be done in a variety of ways, including self-report, behavioral tests and self-monitoring. It is important that we share these findings with our peers and continue to test and refine our practices.

This seminar series also helped solidify our view that practice-based research may be critical in reducing the science–practice gap. Information must flow in both directions — from the laboratory to the clinic, and from the clinic back to the laboratory. We hope that our discussions over these five months have helped lay the groundwork for practice-based research that will contribute to this noble task.

Concluding comments

We (John and Boyd) practice acceptance and commitment therapy and rational emotive behavior therapy, respectively. Both of these evidence-based models are theoretically grounded in the CBT tradition and are transdiagnostic, and they overlap substantially in their approaches. Our view of counseling is aligned with the process-based approach advocated by Hayes and Hofmann, which highlights the advantages of therapists using testable models to employ a versatile range of evidence-based interventions. This approach reflects the complexity and situational specificity of presenting problems and implies a nondogmatic, nuanced, multimodal strategy.

The process-based approach takes to heart Abraham Maslow’s cautionary observation: “I suppose that it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.” In other words, with a predetermined armamentarium in hand, we might be tempted to rigidly and reductively treat diagnostic labels instead of treating our individual clients/patients and their idiosyncratic problems.

Similarly, Arnold Lazarus, cognitive therapist and founder of multimodal therapy, advised therapists to have a variety of tools in their toolbox so that they could “offer a broad-spectrum versus narrow-band treatment approach.” Taking this broad-spectrum approach improves outcomes and prevents future behavioral and emotional problems for our clients.

In keeping with the aforementioned frame of reference, our goals in this seminar series were to:

  • Use Hayes and Hofmann’s influential text as a method of engaging an eclectic group of mental health practitioners on the topic of evidence-based practice
  • Begin to move away from the specific protocols and techniques linked to brand-name therapies for diagnostic syndromes
  • Initiate a conversation about how to effectively target the precise processes that appear to be important across different psychotherapy orientations

Given the overall good receptivity to the seminar series across clinicians, we believe we took steps toward those goals.

Furthermore, we think that this approach is one that is transportable to other clinics. Reflecting on the successful aspects of this seminar series, we recommend:

  • Organizing sessions at a time that is minimally disruptive to the busy schedules of mental health practitioners (for us, that was around lunchtime, but this will vary across settings)
  • Tailoring each session to a specific topic or set of topics
  • Including out-of-session readings that participants can review prior to
    each session

We also hope to extend this work with further trainings, which then may stimulate research questions and encourage practice-based research relevant to the process of therapy. In this effort, we may plant the seeds for the upward dissemination of evidence that will help to answer Gordon Paul’s great question: “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances, and how does it come about?” Or, as is stated in the Process-Based CBT text, “What core biopsychosocial processes should be targeted with this client given this goal in this situation, and how can they most efficiently and effectively be changed?”




Boyd Eustace, a licensed clinical professional counselor and clinical supervisor, sees clients and supervises therapists in a hospital-based mental health clinic and in his private counseling practice in Baltimore. He received training in rational emotive-cognitive behavior therapy at the Albert Ellis Institute and specializes in brief solution-focused individual and couple counseling at LB Counseling Services. Contact him at lbcounseling90@gmail.com or via his website at pcc-mentalhealth.com.

John Donahue is a licensed clinical psychologist and assistant professor of psychology at the University of Baltimore. His clinical and research interests involve mechanisms underlying psychopathology that cut across traditional diagnostic boundaries and the application of mindfulness and acceptance-based approaches to psychotherapy. Contact him at jdonahue@ubalt.edu.


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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.

A script for socialization to the cognitive model

By Brandon S. Ballantyne May 14, 2019

Cognitive behavior therapy (CBT) is an evidence-based treatment approach that has statistically been shown to be effective in addressing a variety of mood disorders and psychological problems. It is my belief that a key component to successful cognitive behavioral treatment is counselor-to-client socialization of theory and concept.

It is essential that clients become socialized to the cognitive model — understanding the rationale behind CBT’s effectiveness — to gain maximum benefit. For that reason, I have developed a script that counselors can use with the clients they serve. This script aims to provide a blueprint for live, in-session socialization to the cognitive model and provides a platform to transition into routine practice of cognitive behavioral technique in future sessions.


Script introduction

If I were to ask you to think of a palm tree, what do you think of? You probably just imagined a palm tree. If I were to ask you to think of your very first car, what do you think of? You probably just imagined yourself either in or next to that memorable first automobile. If I were to ask you to think of your favorite food, what do you think of? You probably just imagined your meal of choice.

Now, if I were to ask you to feel anxious, what do you have to do? Most people say they need to imagine a stressful scenario to feel the emotion of anxiety. The point is that we can instantaneously produce any thought. However, when it comes to producing an emotional state, we first need to think of something in order to feel something.

The formation of emotions is a biological process, meaning that it is impossible to shut off or terminate from human experience unless we suffer serious medical injury that leads to such complications. With that being said, there is a specific sequence of internal and external events that not only create, but contribute to, the emotional experiences of you, me and everyone else with whom we share this wonderful planet.



For an emotion to be formed, one must first encounter a situation. A situation is anything that an individual becomes aware of. It can be an external event such as a person, place, thing or activity. It can also be an internal event such as a particular thought or emotion.

Let’s say that tomorrow, I wake up, get in my car and start my drive into work. I encounter a traffic jam, which I anticipate might make me late to my destination. As I approach, I become aware of the traffic jam itself. Both the awareness of the traffic jam and the traffic jam itself become the situation at hand.



Our brain is like a thought warehouse. It has a job of producing thoughts throughout the day — every second, every minute, every hour.

What is a thought? A thought is a sentence that our brain produces about the situation at hand. Thoughts have sentence structure. Each thought has punctuation. It can also take the form of an image or movie that we experience in our mind.

On some occasions, we verbalize our thoughts out loud. Sometimes they stay silent. Regardless, they affect how we feel. If I am driving to work and become aware of the traffic jam, my brain might produce the thought of, “Oh no! I am going to be late. I am going to be behind all day, and I will get reprimanded by my boss. This happens all of the time!”

The first thoughts that our brain produces about a situation at hand are automatic. We don’t really have control over them. But as I mentioned earlier, these thoughts affect how we feel, so they are important to accept and to understand.



Once our brain produces a thought about a situation at hand, there is the onset of some kind of emotional experience. How is an emotion different from a thought? Emotions can be categorized into mad, sad, glad and fearful. Any emotion that we have at any given time will likely fit into one of these categories of primary emotions.

There is also a subtle category that some identify as “neutral emotions.” However, we are rarely taught about what neutral emotions are. Throughout our life experiences, we are given the message that there must be a way to feel and that emotions need to be either pleasant or unpleasant. Therefore, if we aren’t particularly happy, sad, fearful or mad, we tend to say that we are feeling “nothing.”

Emotions are a biological process. And because our thoughts are automatic, we never really have an absence of emotions. So, when we are feeling “nothing,” we are actually feeling “neutral.” Descriptors such as “content” and “OK” best describe a neutral emotional state.

Now, let’s refer back to the traffic jam scenario. While sitting in the traffic jam, I am having the thought, “Oh no! I am going to be late. I am going to be behind all day, and I will get reprimanded by my boss. This happens all of the time!”

Because of this thought, I am most likely to be feeling anxious. Anxiety is most closely related to the primary emotion of fear. Some emotions occur parallel to physical symptoms as well. For example, if I am sitting in my car feeling anxious from the thought about being late to work, I may also notice that my hands have started to sweat. Physical symptoms help us to identify and label emotions.

So, it is important to pay attention to your patterns in your physical symptoms as you experience emotional states. In general, emotions give us information about the situation at hand. However, it is then our job to examine that information accordingly.



Our behaviors are influenced by the emotions we experience. Behaviors can usually be observed by others. Based on the specific characteristics of the behaviors — and the specific characteristics of the reactions that the behaviors provoke in others — these behaviors can help us to get closer to our goals, push us further from our goals, or neutralize the pursuit of our goals.

What does it mean to neutralize the pursuit of our goals? Well, some behaviors neither get us closer to nor push us further from our goals. These behaviors can be referred to as “neutralizing behaviors.”

In the example of sitting in the traffic jam and feeling anxious, I may react to the intense anxiety by engaging in behaviors such as beeping my horn and yelling at other drivers.



Results can be defined as a set of benefits or consequences that are produced by one particular behavior or set of behaviors. Results can be desirable, undesirable or neutral.

Desirable results are outcomes that take us closer to our goals. Undesirable results are outcomes that push us further from our goals. Neutral results neither take us closer to our goals nor push us further away.

In the traffic jam example, the behavior indicated was beeping the horn and yelling at other drivers. We can anticipate potential results that those behaviors may produce. As a reminder, the goal in that scenario is to get to work on time, or at least not too late, and safely.

One possible result of beeping my horn and yelling at other drivers is that other drivers may begin beeping their horns and yelling at me. This additional conflict may cause my anxiety to intensify further. At the same time, everyone beeping their horns and yelling at each other will not change the fact that I am sitting in the traffic jam itself. Therefore, this outcome can be categorized as an undesirable result.


Wrapping it up

The goal of this type of cognitive behavioral style work is to identify where in the process above an individual may have personal control or personal choice of changing the problematic patterns or tendencies. By examining the above scenario in that way, individuals will be able to conceptualize aspects of personal choice and change that can help them reduce intense emotional distress, engage in healthier behaviors, and achieve more desirable results — first in the above scenario and then with the real-life stressors that have brought them into treatment.

Use the following reflection questions to get started with application of this skill:

1) If you were stuck in a traffic jam similar to the one described above, what would be going through your mind? What are some of the automatic thoughts you would be having?

2) What kinds of emotions would your automatic thoughts produce? Would you be noticing any symptoms of those emotions in your body?

3) What type of automatic behaviors might you engage in based on the influence of those emotions or physical symptoms?

4) What type of outcomes or results would those behaviors likely produce? Would those results be desirable, undesirable or neutral based on your goal of getting to work on time, or not too late, and safely?

5) Is there anything else you might be able to say to yourself in the scenario about the traffic jam that would produce less intense distress? If so, what are those thoughts? Remember, thoughts come in the form of sentences or images.

6) If you were able to insert those new thoughts the next time you experience a traffic jam, what types of emotions would those thoughts likely produce? If they do not produce less intense distress or new emotions comprehensively, try identifying new thoughts (sentences) until you find one or two that either reduce the distress or produce new desirable emotions.

7) With less intense distress or new desirable emotions, what are the new behaviors that likely would be produced as a result?

8) Given the likelihood of those new behaviors, what would happen next? In other words, what would be the results of those new behaviors? Would those results be desirable, undesirable or neutral based on the goal of getting to work on time, or not too late, and safely? If those results are desirable or neutral, then you have successfully completed examination of this scenario. If the results are undesirable, repeat steps 1 through 8 until you are left with desirable or neutral results. If a neutral result does not make the situation worse, then it is desirable in itself.

9) What are some situations in your life that have caused stress?

10) What were the automatic thoughts running through your mind at the time?

11) Given those life situations, what were the undesirable results that were occurring?

12) Given those life situations, what were the behaviors that were contributing to those undesirable results?

13) Looking back, could you have said anything different to yourself in those moments to reduce the level of stress? If so, what would those coping thoughts be?

14) Given those life situations, what are examples of healthier behaviors that you want to be able to engage in?

15) Given those life situations, what emotions would be needed to make those healthier behaviors easier to achieve?

16) Given those life situations, what results would you want to be able to achieve, experience or receive?

17) With those desired results in mind, what can you say to yourself about those life situations that might help to produce healthier emotions and healthier behaviors?

18) Copy down those thoughts. Put them on an index card. This will serve as your coping cue to take with you. It will be a reminder that although we may not be able to fix a stressor at hand, we do have the opportunity to access alternative thoughts. It is those alternative thoughts that kickstart the process of reduced distress, healthier behaviors, and the satisfying experience of more desirable results. Thus, we are creating an opportunity for achievement as we assist ourselves in getting closer to our goals, even if certain stressors stay the same. With consistent practice, we teach our brains that we control our thoughts, emotions and behaviors. We give power to ourselves in knowing that we do not need situations to change in order to feel better and do better.




Brandon S. Ballantyne has been practicing clinical counseling for 12 years. He is a licensed professional counselor and national certified counselor who specializes in the treatment of anxiety and depression. He currently practices at a variety of different agencies in eastern Pennsylvania. Find him on the web at https://thriveworks.com/bethlehem-counseling/our-counselors/, and contact him at brandon.ballantyne@childfamilyfirst.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.

What’s left unsaid

By Lindsey Phillips January 3, 2019

A child discloses that her grandfather has been sexually abusing her, and the mother’s response is shock that his abuse didn’t stop with her when she was a child. This scene is not uncommon for Molly VanDuser, the president and clinical director of Peace of Mind, an outpatient counseling and trauma treatment center in North Carolina. As she explains, adult survivors of child sexual abuse often assume that the offender has changed or is too old to engage in such actions again. So, the abuse persists.

Concetta Holmes, the clinical director of the Child Protection Center in Sarasota, Florida, has treated clients with similar intergenerational abuse stories. “In that unresolved trauma … what has happened is now a culture of silence around sexual violence that is ingrained in the family,” she says. “That [affects] things like your feelings of safety, security [and] trustworthiness, and it reinforces that you should stay with people who hurt you.”

Kimberly Frazier, an associate professor in the Department of Clinical Rehabilitation and Counseling at Louisiana State University’s Health Sciences Center, acknowledges that people often don’t want to think or talk about child sexual abuse, but that doesn’t stop it from happening. The nonprofit Darkness to Light reported in 2013 that approximately 1 in 10 children will be sexually abused before they turn 18.

Because of the culture of silence that surrounds child sexual abuse, it is safe to assume that the true number is even higher. Cases of child sexual abuse often continue for years because the abuse is built on a foundation of secrets and fear, Frazier points out. Survivors frequently fear what will happen to them (or to others) if they tell, or the shame they feel about the abuse deters them from disclosing.

Societal norms can also diminish a survivor’s likelihood of disclosing. For example, society has for decades implicitly sanctioned sexual interactions between boys who are minors and adult woman, but it is still abuse, says Anna Viviani, an associate professor of counseling and director of the clinical mental health counseling and counselor education programs at Indiana State University. Holmes adds that gender stereotypes such as this can cause boys to feel as though they shouldn’t be or weren’t affected by sexual abuse, which is not the case.

“I think the biggest fallacy [counselors have] is that [child sexual abuse] is going to impact people from a particular demographic more than another,” Viviani says. “Childhood sexual abuse cuts across every demographic. I think the sooner we can accept that, the sooner we’re going to be better at identifying clients when they have this issue in their history.”

Putting on a detective hat

Identifying signs of child sexual abuse is neither easy nor straightforward. Part of the difficulty lies in the fact that the signs are not clear-cut, says VanDuser, a licensed professional counselor (LPC) and an American Counseling Association member. Regressive behaviors such as bed-wetting can indicate abuse, but they might also be the result of other changes such as a recent move, a new baby in the family or a military parent deploying, she explains.

VanDuser also warns that child sexual abuse is insidious because a lot goes on before the offender actually touches the child. “Childhood sexual abuse sometimes leaves no physical wounds to identify,” she says. Some examples of noncontact abuse include peeping in the window at the child, making a child watch pornography or encouraging a child to sit on one’s lap and play the “tickle game.” Such activities are part of the grooming process — the way that offenders build trust and gain access to the child.

In addition to physical signs such as bladder and vaginal infections, changes in eating habits, and stomachaches, survivors of child sexual abuse also demonstrate behavioral and emotional changes. One major warning sign is if the child displays a more advanced knowledge of sex than one would expect at the child’s developmental stage, VanDuser says.

Other possible behavioral signs include not wanting to be alone with a certain person (e.g., stepfather, babysitter), becoming clingy with a nonoffending caregiver, not wanting to remove clothing to change or bathe, being afraid of being alone at night, having nightmares or having difficulty concentrating. In general, counselors should look for behaviors that are out of character for that particular child, VanDuser advises.

Viviani, a licensed clinical professional counselor and an ACA member, also finds that people who have experienced child sexual abuse have higher rates of depression, anxiety, panic disorders and posttraumatic stress disorders.

Because the signs of child sexual abuse are rarely clear-cut, counselors must be good investigators, Viviani argues. In her experience, adult survivors present with an array of symptoms, including health concerns, relationship problems and gaps in memory, so counselors have to look for patterns to discover the underlying issue.

If counselors notice any of these signs, VanDuser recommends asking the client, “When did this problem (e.g., bed-wetting, cutting, nightmares, acting out in school) begin?” Counselors can then follow up and ask, “What else was going on at that time?” The answers to these questions often reveal the underlying issue, she notes. For example, if the client responds that his or her depression or vigilance to the environment began around age 12, VanDuser says she will dig deeper into the client’s family relationships.

Frazier, an LPC and a member of ACA, suggests that counselors can also look for patterns in a child’s drawing — for example, what colors they use, how intensely they draw with certain colors, or if they scratch out certain people or choose not to include someone — or in the choices children make with activities such as feeling faces cards (cards that depict different emotional facial expressions). When Frazier asked one of her clients who had come to counseling because of suspected sexual abuse to select from the feeling face cards, she noticed the client consistently picked cards with people wearing glasses. Frazier later discovered that the child’s abuser wore glasses.

For Frazier, becoming a detective also involves going outside of the office to observe the child in different spaces, such as in school, in day care or at the park. Frazier includes the possibility of outside observations in her consent form, so the child’s parent or guardian agrees to it beforehand. She advises that counselors should take note of whether the child’s behavior is consistent across all of these spaces or whether there are changes from home to school, for example. In addition, she suggests asking the parents or guardians follow-up questions about how the child’s behavior has changed (e.g., Has the child lost the joy of playing his or her favorite sport? Is the child withdrawn? Is the child fighting?).

Speaking a child’s language

Young children may not have the words or cognitive development to tell counselors about the abuse they have been subjected to. Instead, these children may engage in traumatic play, such as having monsters in the sand tray eat each other or being in a frenzied state and drawing aggressive pictures, VanDuser says.

“One of the most important things for clinicians to remember when they’re working with kids and abuse is that it’s really critical to be working within the languages that children speak,” says Holmes, a licensed clinical social worker and a nationally credentialed advocate through the National Organization for Victim Assistance. “Children speak through a variety of different languages that aren’t just verbal. They speak through play. They speak through art, through writing [and] through movement, so it becomes really important that clinicians get creative in using evidence-based practices and different modalities to talk with children through their language. … Talking in a child’s language allows them to feel like the topic at hand is less overwhelming and less scary.”

For example, children can use Legos to build a wall of their emotions, Holmes says, with counselors instructing clients to pick colors to represent different emotions. If orange represents sadness and red represents frustration and 90 percent of the child’s wall contains orange and red Legos, then the counselor gets a better visualization of what emotions are inside the child, she says.

Next, counselors could ask clients what it would take to remove a red brick of frustration or what their ideal wall would look like, such as one that contains more bricks representing happiness or peace. Counselors can also ask these clients to rebuild their Lego walls throughout therapy to see how their emotions are changing, Holmes says. This method is easier than asking children if their anger has decreased and by how much, she adds.

Frazier, past president of the Association for Multicultural Counseling and Development, a division of ACA, also finds that working with children keeps counselors on their toes. Children are honest and will admit if they do not like an intervention, so counselors have to be ready to shift strategies quickly, she says. For this reason, counselors need to have a wide range of creative approaches in their counseling bag. She recommends drawing supplies, play school or kitchen sets, play dough and sand trays.

With sand trays, Frazier likes to provide dinosaurs and other nonhuman figurines for children to play with because it helps them not to feel constrained or limited. This allows them to freely let a dinosaur or car represent a particular person or idea, she explains.

Frazier also recommends the “Popsicle family” intervention, in which children decorate Popsicle sticks to represent their family members and support systems. This exercise provides insight into family dynamics (who is included in the family and who isn’t) and allows children to describe and interact with these “people” like they would with Barbie dolls, she says.

Frazier advises counselors to keep culturally and developmentally appropriate materials on hand. For example, they should have big crayons for young children with limited fine motor skills, and they should have various shades of crayons, markers, pencils and construction paper so children can easily create what they want.

Being multiculturally competent goes beyond ethnicity, Frazier points out. Counselors should understand the culture the child grew up in and the culture of the child’s current locality because what is considered “normal” in one city or area might differ from another, she says. For example, in New Orleans, where she lives, people regularly have “adopted” family members. So, if a child from New Orleans were creating his or her Popsicle family, it wouldn’t be strange to see the child include several people outside of his or her immediate family and refer to them as “cousin” or “aunt,” even if they aren’t blood relatives.

Thus, Frazier stresses the importance of counselors immersing themselves in the worldview of their child clients. “You can’t be a person who works with kids and not know all the shows and the stuff that’s happening with that particular age group, the music, the things that are on trend and the things they’re talking about,” Frazier says. “Otherwise, you’ll always be behind trying to ask them, ‘What does that mean?’”

With adolescents, Holmes finds narrative therapy to be particularly effective, and she often incorporates art and interview techniques into the process. For example, the counselor could ask the client to draw a picture of an emotion that he or she feels, such as anger. Next, the client would give this emotion a name and create a short biography about it. For example, how was anger born? How did it grow up to be who it is? What fuels it? Why does it hang around?

Next, Holmes says, the counselor and client could discuss the questions the client would ask this emotion if it had its own voice. Then, the client could interview the initial picture of the emotion and use his or her own voice to answer the questions as the emotion would. The answers provide insight into the emotional distress the client is feeling, Holmes explains.

Frazier will do ad-lib word games with older children, who are often more verbal. While clients fill in the blanks to create their own stories, she looks for themes (e.g., gloomy story) or the child’s response to the word game (e.g., eager, withdrawn). 

Long-lasting effects

Unfortunately, the effects of child sexual abuse don’t end with childhood or even with counseling. “Children revisit their trauma at almost every age and stage of development, which is every two to three years,” Holmes notes. “That might not mean they need counseling each and every time, but they find new meaning in it or they find they have new questions … or new emotions about it.”

Viviani, VanDuser and Frazier agree that recovery is a lifelong process. As survivors age, they will have sexual encounters, get married, become pregnant or have their child reach the age they were when the abuse occurred. These events can all become trigger points for a flood of new physical and emotional symptoms related to the child sexual abuse, Viviani says.

Often, an issue separate from the abuse causes adult survivors to seek counseling. In fact, VanDuser says she rarely gets an adult who discloses child sexual abuse as the presenting issue. Instead, she finds adult clients are more likely to come in because their own child is having behavioral problems or because they’re feeling depressed or anxious, they’re having nightmares or they’re married and have no interest in sex.

Adults survivors often experience long-term physical ailments. According to Viviani, who presented on this topic at the ACA 2018 Conference & Expo in Atlanta, some of the ailments include diabetes, fibromyalgia and chronic pain syndromes, pelvic pain, sexual difficulties, headaches, substance use disorders, eating disorders, cardiovascular problems, hypertension and gastrointestinal problems.

Another long-term issue for survivors is difficulty forming healthy relationships. Because child sexual abuse alters boundaries, survivors may not realize when something is odd or abusive in a relationship, VanDuser says. For example, if an adult survivor is in a relationship with someone who is overly jealous and possessive, he or she may mistakenly translate that jealously into a sign of love.

Child sexual abuse can also affect decision-making as an adult around careers, housing, personal activities and sexual intimacy, Viviani notes. For example, one of her clients wanted to attend a Bible study group but didn’t feel safe being in a smaller group where a man might pay attention to her. In addition, Viviani finds that adult survivors sometimes choose careers they are not interested in just because those careers provide a safe environment with no triggers.

To help adult clients make sense of the abuse they suffered as children and move forward, Viviani often uses meaning-making activities and mindfulness techniques. She suggests that counselors help these clients find a way to do something purposeful with their history of abuse, whether that involves sharing their story with a testimony at church, volunteering for a mental health association or participating in a walk/run to raise awareness of suicide prevention.

Finding self-compassion

Survivors of child sexual abuse often blame themselves for the abuse or the aftermath once the abuse is revealed, especially if it results in the offender leaving the family, the family losing its home or the family’s income dropping, VanDuser says. One of her clients even confessed to thinking that she somehow triggered her child sexual abuse from her stepfather.

“Sometimes the worst part is the dread [when the child knows the sexual abuse is] coming eventually. So, sometimes a teenager will actually initiate it to get it over with because the only time they feel relief is after it’s done,” VanDuser explains. “Then they know for a while that they won’t be bothered again.”

Counselors often need to shine a light on survivors’ cognitive distortions to help them work through their guilt and shame, VanDuser says. She tries to help clients understand that the sexual abuse was not their fault by changing their perspective. For example, she will take a client to a park where there are children close to the age the survivor was when the abuse happened. She’ll point to one of the children playing and ask, “What could the child really do?” This simple question often helps clients realize that they couldn’t have done anything to prevent the abuse, VanDuser says.

Viviani takes a similar approach by talking with clients in the third person about their expectations of what a child would developmentally be able to do in a similar situation. She asks clients if they would blame another child (their grandchild or niece, for example) for being sexually abused. Then she asks why they blame themselves for what happened to them because they were also just children at the time.

“As you frame it that way, they begin to have a little bit more compassion for themselves, and self-compassion is something that’s so important for survivors to develop,” Viviani says. In her experience, survivors are hard on themselves, often exercising magical thinking about what they should or should not have been able to do as a child. “As we help them develop self-compassion and self-awareness, we see the guilt begin to dissipate,” she adds.

Regaining a sense of safety

Safety — in emotions, relationships and touches — is a critical component of treatment for a child who has been sexually abused, Holmes stresses.

Counselors should teach clients about safe and unsafe touches, personal boundaries and age-appropriate sexual behavior rules, adds Amanda Jans, a registered mental health counseling intern and mental health therapist for the Child Protection Center in Sarasota. Counselors can also help clients “understand that they are in charge of their bodies, so even if a touch is safe, it doesn’t mean they have to accept it,” she says.

Hula hoops provide a creative way to discuss personal space boundaries with clients, Holmes notes. Counselors can use hula hoops of different sizes to illustrate safe and unsafe boundaries with a parent, sibling, friend or stranger, she explains.

VanDuser helps clients engage in safety planning by having them draw their hand on a piece of paper. For each finger, they figure out a corresponding person they can tell if something happens to them in the future.

Counselors can also take steps to ensure that their offices are safe settings. Jans, an ACA member who presented on the treatment of child sexual abuse at the ACA 2018 Conference, uses noise machines to ensure privacy and aromatherapy machines to make the environment more comfortable. She also has a collection of kid-friendly materials, so if a child starts to feel dysregulated during a session, he or she can take a break and play basketball or color.

Likewise, if clients are hesitant to discuss the topic, Jans allows them to take a step back. For instance, she has clients read someone else’s experience (either real or fictional) rather than having them write their own story, or she has clients role-play with someone else serving as the main character, not themselves. This distance helps clients move to a place where they eventually can discuss their own stories, she says.

Another technique Jans uses to ease clients into writing and processing their own stories is a word web. Together, Jans and a client will brainstorm words related to the client’s experience and put the words on a web (a set of circles drawn on a paper in a weblike pattern). Jans finds this exercise helps clients get comfortable talking about the subject and, eventually, these words become part of their narrative.

VanDuser also suggests getting out of the office. Sometimes she takes child and adolescent clients to a store to get a candy bar. On the way, she will ask them what they are feeling or noticing. If clients say that someone walking by makes them feel strange, VanDuser asks how they would address this feeling or what they would do if someone approached them. Then they will talk through strategies that would make the client feel safe in this situation.

Taking back control

Survivors of child sexual abuse often feel they can’t control what happens around them or to them, Frazier says. So, counselors can get creative using interventions that return control to these survivors and make them feel safe.

Viviani helps clients regain some sense of control in their lives by teaching grounding and coping skills. “Coping skills are so important to helping them begin to trust in themselves again so that they have the skills to really uncover and deal with the abuse,” she explains.

In sessions, counselors can help clients recognize what their bodies feel when they are triggered. Then they can help clients learn to deescalate through grounding skills such as noticing and naming things in their current surroundings or reminding themselves of where they are and the current date, Viviani says. Rather than reliving the incident — being back in their bedroom at age 5, for example — clients learn to ground themselves in the here and now: “This is Jan. 10, 2019, and I’m sitting in my office.”

VanDuser highly recommends trauma-focused cognitive behavior therapy (TF-CBT) for work with survivors of child sexual abuse. TF-CBT is a short-term treatment, typically 12-16 sessions, that incorporates psychoeducation on traumatic stress for both the child and nonoffending parent or caregiver, skills for identifying and regulating emotions, cognitive behavior therapy and a trauma narrative technique.

For a creative approach, VanDuser suggests letting children use crayons and a lunch bag to create a “garbage bag.” She first writes down all the bad feelings (e.g., fear, anger, shame) the client has about the abuse. As the child finishes working on one of the bad feelings, he or she puts the feeling in the garbage bag. When all the feelings are in the bag, VanDuser lets the client dispose of it however he or she wishes — by burning it, burying it, throwing it in the actual garbage or some other method.

Jans and Holmes suggest empowering clients by giving them some control in session. For example, if clients are feeling sad, the counselor can remind them of the coping strategies they have been working on (perhaps progressive muscle relaxation and grounding techniques) and ask which one they want to use to address this feeling. The counselor could also list the goals of therapy for that day and ask clients which one they want to work on first, Holmes says.

Holmes acknowledges that clients may never make sense of the abuse they suffered, but counselors can help them make sense of the abuse’s impact and aftermath. For Holmes, this meaning making involves clients being empowered to reclaim their lives after abuse rather than being held hostage by it, realizing that trauma doesn’t have to define them and learning to be compassionate with themselves.

The hero who told

Holmes encourages counselors not to shy away from discussing child sexual abuse. “If clinicians hesitate, clients will hesitate. If the clinician avoids it, the client will avoid it,” Holmes says. “It’s the clinician’s responsibility to take the lead on this topic. Sexual abuse is so widespread in our society that we do our clients a disservice when we don’t incorporate sexual abuse histories into our [client] assessments.”

Typically, however, counselors are not the first person a child will tell about the abuse. Often, children first disclose the abuse to a teacher or other school personnel, and their reaction is crucial in ensuring that the child gets help, Viviani says.

Thus, she advises counselors to partner with schools and child advocacy organizations to educate them on what they should do if a child discloses sexual abuse. “They need to know what to do,” Viviani emphasizes. “They need to know what to say to support that child because we may not get another chance, at least until they hit college age when they’re not under that roof anymore, or we may never get that chance again.”

Counselors must also empower survivors of child sexual abuse. “They shouldn’t be waiting for the therapist … or their best friend to ride in and save them. We want them to be the hero of their own story,” Holmes says. “And how we do that is through finding ways they can start to recognize and make safe and healthy decisions about different pieces of their life, and we want to model that even within the therapy environment.”

The end result of TF-CBT is the child writing his or her own narrative of the sexual abuse. VanDuser emphasizes that no matter how the child’s sexual abuse story begins, it always has the same ending: the hero — the child — who told.




Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at consulting@lindseynphillips.com or through her website at lindseynphillips.com.

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