Tag Archives: Coronavirus

Treating clients with long COVID

By Lisa R. Rhodes November 1, 2023

Woman pulling down her face mask with one hand; other hand holding her head; sitting in front of a laptop and open book; eyes closed and looks in pain

Dragana Gordic/Shutterstock.com

Alicia Dorn, a licensed clinical professional counselor in Maryland, has had clients come to see for help managing the emotional toll that comes with living with long COVID — a condition that the Centers for Disease Control and Prevention (CDC) defines as “a wide range of new, returning, or ongoing health problems that people experience after being infected with the virus that causes COVID-19.” The health issues that can develop from long COVID (such as chronic fatigue, memory difficulties, insomnia, and changes in smell or taste) can last weeks, months or years after the initial diagnosis, and although these symptoms typically occur in people who experienced a severe bout of COVID-19, anyone who has been infected can get long COVID.

As researchers work to discover the causes of long COVID and ways to prevent and treat the condition, counselors like Dorn are helping clients learn to manage the anxiety, depression and grief that results from experiencing this new chronic condition.

“I first help my clients by validating the emotional experience for them. They’re not wrong for feeling out of touch with themselves and angry that things aren’t getting better,” Dorn says. “Although we can’t change the diagnosis or how the symptoms arrived, we [can] focus on what’s within their control and help them find meaning there.”

Facing the unknown

Dakota Lawrence, a licensed professional counselor with a private practice in Tennessee, has been treating clients with long COVID for two years. He says the long-lasting symptoms cause many clients to worry whether they will ever get relief so their lives can return to “normal.”

“They also worry about getting sick again, either with COVID or another virus, further impacting their physical health,” Lawrence continues. And some clients who struggle with depression often express a sense of hopelessness about the future or worry they are a burden to their loved ones, he says.

Although none of Lawrence’s clients with long COVID currently meet the diagnostic criteria for posttraumatic stress disorder, some of them consider the sudden and long-lasting change in their health status to be traumatic.

Dorn says the uncertainty about long COVID can make it difficult for clients to rebuild their lives after they are diagnosed with it. “Clients with long COVID often do not recognize themselves in comparison to who they were before they got COVID,” she explains. “It’s harder sometimes to return to school or work successfully with long COVID because there is not much information out there on it, and many employers and schools don’t know how to best accommodate living with the condition.”

Long COVID in children

Like adults, children and adolescents are susceptible to experiencing long-term health symptoms after they have had COVID-19. The Kennedy Krieger Institute in Baltimore created the Pediatric Post-COVID-19 Rehabilitation Clinic to help children and adolescents who have recovered from COVID-19 but still need additional support for lingering neurological and physical issues related to the illness. The patients at this clinic range in age from 2 to 21 years and often present with abdominal pain, muscle or joint aches, nausea or vomiting, skin rashes, numbness in the extremities and recurrent fevers. They also struggle with anxiety and depression.

Ellen Henning, a psychologist who works as a consultant at the clinic, provides assessments and recommendations for each young person. “We take a functional rehabilitation approach to treatment. We make recommendations to help each patient reach the next level of functioning with the ultimate goal of helping them get ‘back to play,’ which can be school and extracurricular activities,” she explains. “Many times, we are concurrently addressing both physical symptom management and mental health concerns.”

Henning says long COVID affects each person at the clinic differently. “Some patients … are able to continue their typical routine but notice bothersome symptoms throughout the day,” she explains. “Other patients have difficulty attending school or have to stop major life activities, like extracurricular activities or sports, due to the symptoms.”

Young people who are living with ongoing pain, fatigue or other symptoms of discomfort may find commuting between classes or staying up late after school to complete homework assignments to be challenging, Dorn adds.

Grieving changes and losses   

Helping adults and youth deal with grief and loss is also a necessary part of managing the psychological pain of living with long COVID. Henning says patients who have not dealt with a major illness or health issue before getting long COVID feel a loss of typical daily functioning. For example, attending a full day of school can lead to energy “crashes” at the end of the day. Even spending time with friends can be exhausting, she adds.

“I allow space to discuss loss if the patient wishes to, but [I] am also respectful of boundaries if they do not,” Henning says. “By taking a functional rehab approach, we meet the patients where they are currently and help set gradual goals to help [with] increased functioning so [they will ideally] be able to get back to their previous functional level or at least be able to create a routine that is acceptable to the patient, along with strategies for symptom management.”

Lawrence has noticed that some of his clients with long COVID hyper-fixate on losses from the past or uncertainties about the future. He often uses mindfulness-based cognitive therapy to help them develop and implement a regular mindfulness practice. “Mindfulness is wonderful for increasing tolerance of uncertainty, regulating difficult emotions, tolerating difficult physical sensations and coping with anxious or depressive cognitions,” he says. And it’s “incredibly useful in orienting them to the present, which is often less painful or anxiety provoking.”

Dorn often uses acceptance and commitment therapy because it helps clients grieve the changes in their lives that they can’t control. With this approach, counselors can help clients learn skills, such as mindfulness, to regulate their nervous system and ways to treat themselves with compassion so they can learn to move forward.

People with long COVID are reminded daily about how the virus has taken a major toll on their body, and the condition often makes them feel helpless, Dorn notes. “Sometimes they only want a listening ear and someone to believe [their] experience without judgment or questions,” she says.

Clients sometimes struggle with feelings of bitterness or resentment about getting long COVID, Lawrence adds. Clients may feel they “did everything right” during the pandemic; they got vaccinated, practiced social distancing and wore a mask, yet they still got sick. And their experience with COVID is different than most of their peers who quickly recovered from the virus.

These clients “struggle with a sense of injustice or unfairness,” Lawrence explains. He uses somatic and mindfulness-based strategies to help these clients to reflect on and manage their emotions. For example, he may ask a client, “Where do you feel that anger, sadness or grief in your body?” or “When you make space for the pain and allow it to be, how does it change?” He says that helping these clients realize that it is OK to feel upset is often the first step to moving past their distress.

No easy answers

Research about long COVID continues to emerge, and mental health professionals are also learning important lessons as they help clients to move forward in their journey with this chronic condition.

“When I first started working with patients with long COVID, I remember it feeling daunting because it was so new. There were no manuals for it,” Henning recalls. “We still have a lot to study and understand better, but anecdotally, we have found that [by] applying information from other populations (e.g., chronic pain, concussion, headache/migraine), we have been able to make great strides with this population.”

Dorn recommends that counselors consult with the client’s physician and any other health care providers to keep abreast of developments in the client’s health. She also says counselors should keep up with the latest research about long COVID. “Be aware of how viruses affect mental and physical health outcomes over time and encourage [clients] to follow up with their doctor if new symptoms arise,” she advises.

Clients may come to therapy asking about treatments and the long-term effects of long COVID — questions for which there are still no clear answers. “COVID is so new to the world. Long COVID is even newer,” Lawrence says. “Counselors must be comfortable sitting in the discomfort of the unknown” while still helping clients to process and accept the present.


Learn more about treating clients who are dealing with chronic health conditions in the November cover story, “Coping with the stress and uncertainty of chronic health conditions.”

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.

The benefits of a multisensory experience in therapy

By Ashley Heintzelman February 14, 2023

a child points to drawings of shapes on a whiteboard and a woman sits in the chair watching the child

Studio Romantic/Shutterstock.com

Since the beginning of the pandemic, I have been providing and receiving in-person and virtual therapy. Initially, my own therapy was 70% virtual and 30% in person, and my client schedule averaged about 60% in person and 40% virtual. Being on both sides of the couch gave me a unique perspective to consider the advantages and limitations of virtual therapy.

I have always viewed my own therapy process as staying active at the “mental gym” to help me cope with anxiety and for self-care. My anxiety symptoms manifest with challenges regarding perfectionism and being cognitively inflexible during times of change. Unsurprisingly, the COVID-19 pandemic triggered my anxiety.

Although it was not an initial goal of my own therapy, I relearned something I had known about myself and human nature: our need to use all our senses and connect the mind with the body. Throughout this process, I discovered that in-person therapy best meets my needs (and most likely my clients’ needs) because virtual therapy often lacks a multisensory experience.

Finding the right fit

I have attended therapy throughout my professional life, but moving to a new home, raising children and other life challenges have led to periods without therapy. When the pandemic began, I was not currently engaged in counseling, but I recognized the added stress of these circumstances for everyone, including me, made this a good time to continue therapy again.

I had several goals this time. First, I wanted to process coping with the same issues many others faced as the pandemic progressed (e.g., school closings, vaccination decisions). Second, I explored how the pandemic affected me professionally as a therapist. Clients typically do not know much about the lives of their therapists unless mental health professionals choose to self-disclose. The idea that the pandemic and telehealth might lead to added exposure of my personal life to clients triggered a fear of loss of competently managing the potential changes in the therapeutic relationship. I wanted to ensure I found a good balance of self-disclosure for my clients.

When I decided to reenter therapy in 2020, I found a counselor who offered only virtual appointments. Telehealth was more accessible for me with my responsibilities at the time, and it also made sense given the uncertainties of life and the shifting work schedules during the pandemic. I was lucky to find Sophia (pseudonym). She was a good fit for me. She is soft-spoken, nonjudgmental, gently challenging and intelligent. She conveyed support and understanding and shared additional perspectives. Sophia appropriately self-disclosed about her experiences as a clinician and working parent of young children during the pandemic. I felt she understood my anxieties. Her compassion and shared experiences helped normalize and diffuse my fears. And she helped me set realistic expectations of myself.

Even though I was making good progress with Sophia and most of my own work as a therapist was virtual, I felt something was missing from my virtual sessions with her. I just couldn’t put my finger on it yet. It wasn’t until I experienced multisensory engagement in therapy again that I realized that was what was missing.

A multisensory experience

In the spring of 2021, I decided to transition to a new counselor — one I could meet in person. A good friend and colleague recommended I see Lily (pseudonym), a therapist my friend thought would be a good fit for me. When I started with Lily, I felt immediate comfort and ease with her.

During my third session, we explored whether I needed a shift in work-life balance and discussed the potential barriers that made that change difficult. Lily responded saying, “I need to draw this out.” She then drew a model concept of what we discussed regarding my shame, anxiety and boundaries on a whiteboard. We were in sync concerning the model; it made sense to me.

The model created one of those powerful moments in therapy where I felt understood and validated. The use of the whiteboard also highlighted the multisensory experience that I felt was missing during my virtual sessions with Sophia. I could now better articulate how I felt after seeing what she was saying drawn out. The model also contained the trigger point where my anxiety would begin to ramp up, so it allowed me to gain a new coping strategy that I could use moving forward when I felt anxious because I could better understand what started an irrational thought loop. The visual display of my feelings and fears helped me gain a new perspective about my emotions. After Lily finished the whiteboard model, I took a picture of her drawing using my cell phone, which allowed me to view it whenever I felt overwhelmed.

Lily continues to use the whiteboard in session with me, and every time, I process even more sensory details from the experience. I have noticed, for example, that Lily is left-handed, and the slant of her wrist reminds me of my left-handed daughter. I have often watched her dangly earrings bounce while her arm moves when writing, and I have observed how her nail colors change with the seasons.

Being in person also engages my senses in other ways. I sometimes contemplate the exact shade of the moody dark gray paint in her office. I have noticed how the office smells of mint and vanilla, and I wonder if the scent is the remains of essential oils or a candle. I hear the hum of the white noise machine in the hall. Lily’s calming energy permeates the room — a full in-person experience matters in many ways. And I feel safe on her couch, sitting next to a soft blanket in her warm office.

The exposure of all my senses to the surroundings helps me stay grounded during our sessions. The multisensory engagement creates a calming effect on my whole body — one I could not have experienced remotely from a screen. In addition, the surroundings and in-person contact enhance my ability to fully take in Lily’s feedback. Although a multisensory experience is not necessary for change, this experience with Lily reminded me of what I often miss when doing virtual therapy: the benefit of engaging the mind and body.

My knowledge and experiences are consistent with research on the science of calm approach to emotional well-being and the neuroscience of learning, which emphasizes that we learn best when multiple senses are stimulated. For example, Dr. Daniel Siegel, a prominent mindfulness researcher, explored learning to focus and become more aware via practices using our five senses and feeling of connection to other people in his 2020 book Aware: The Science and Practice of Presence — The Groundbreaking Mediation Practice. Dr. Siegel found that sensory experiences and feelings of connection to others promote the growth of neural connections, leading to less stress and anxiety. Thus, the lack of a three-dimensional experience that activates all the senses and helps to stimulate novel ideas could hold clients back from powerful and lasting breakthroughs.

The whiteboard exercise that Lily used during our session symbolizes the strength of the therapeutic alliance. It instantly reminded me of my vulnerability as well as Lily’s unconditional positive regard and brilliant conceptualizing skills. And the experience also helped me learn a new cognitive and emotional framework for coping. This opportunity was therapy at its finest.

Incorporating sensory elements with clients

Drawing on my personal experience in therapy, I continue to think about how to incorporate multisensory experiences during my own professional sessions with clients. In the past, I mapped out client conceptualizations of presenting concerns or coping strategies on paper during sessions. But based on my experience with Lily, I realized how I was underutilizing multisensory engagement as a therapeutic tool. Using the large windows in my office and pens made for writing on glass, I can map and draw out concepts to help clients have more sensory experiences, which will help them visual it better.

I am also seeking to experience my senses and body movements in the presence of clients and recognize the clients’ bodies and movements and verbal descriptions of sensory and emotional experiences. For example, I am now more attuned to clients’ and my own body language after observing Lily’s body language when drawing on the whiteboard.

Clinicians can also explore how to increase multisensory engagement virtually and consider if certain clients may benefit more from multisensory and in-person sessions. For example, clients with anxiety who have a treatment goal of calming their overactive sympathetic nervous system may benefit more from in-person counseling than a client who is primarily working on improving depressive symptoms.

Because the pandemic is ongoing and our lives are demanding, we must be realistic. The convenience of virtual sessions will likely continue to create demand among clients. It’s important to remember that having a therapist who is a good fit is always a better choice than not going to counseling because of a lack of in-person opportunities. Therefore, the best-case scenario might be a hybrid model, depending on the clients’ and therapists’ joint decisions. But no matter if counseling is virtual or in person, I encourage other clinicians to find ways to emphasize the sensory experience in session, including visually mapping concepts.


photo of Ashley Heintzelman


Ashley Heintzelman is a licensed psychologist who specializes in the treatment of eating disorders. She is the founder of the Ampersand Psych Clinic in Overland Park, Kansas, and co-author of the book Free to Be: The Non-Diet Path to Peace With Food and Body. Her other clinical passions include mentoring early career professionals and supervising graduate students in training to become counselors. Contact her at heintzelman.ashley@gmail.com or through her website at ampersandpsychclinic.com.

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit 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.

Looking back, moving forward: COVID-19 and Indian Country

By Nicola A. Meade, Roni K. White and Carol ZA McGinnis November 10, 2022

Throughout American history, the United States government, despite well-documented treaties, has unjustly treated Native Americans. Treaties ratified in 1851 and 1868 were violated during the COVID-19 pandemic national emergency, which may be surprising to people who believe that the failure to uphold such legal documents is an outdated issue. 

As noted by the Substance Abuse and Mental Health Services Administration (SAMHSA), there are eight domains of wellness — physical, relational, occupational, mental/emotional, intellectual, spiritual, environmental and financial — and any domain can affect another. This article will highlight how COVID-19 disproportionately impacted several domains of wellness for Native people and how counselors can address increased mental health concerns. 

The physical toll 

In a December 2021 article published in The Princeton Review, Riis Williams reported about a study conducted by Princeton University researchers, which found that U.S. COVID-19 mortality rates of Native Americans were 2.8 times higher than white people. Comparatively, this study also found that mortality rates were 1.6 higher for Black Americans and 1.8 higher for Latinos than white people. Comorbid factors contributing to these significantly higher rates include lack of access to affordable health care, poverty, historical and current treatment by the U.S. government, and higher rates of high-risk health issues. 

Shortly after the pandemic began, Kolby KickingWoman highlighted a distressing problem in a June 2020 article published in Indian Country Today, writing that “tribal leaders are working to keep their citizens safe from the coronavirus while juggling attacks on tribal sovereignty.” For example, in April 2020, the Cheyenne River Sioux and Oglala Sioux tribes implemented highway checkpoints for the purpose of contact tracing to reduce the spread of COVID-19. According to a May 2020 article in Indian Country Today, Cheyenne River Sioux Chairman Harold Frazier said that vigilance was required because the health care system on his reservation had “only eight hospital beds and six ventilators,” which was alarming given the high rate of infection that was occurring in the United States at the time. Nevertheless, South Dakota Gov. Kristi Noem tried to stop these efforts by giving the Native nations a 48-hour timeline to remove the checkpoints. The Cheyenne River Sioux Chairman Frazier and Oglala Sioux Tribe President Julian Bear Runner ignored the order, stating that they would remove the checkpoints when they deemed that it was safe to do so. Gov. Noem then involved the Bureau of Indian Affairs and threatened legal action. In May 2020, an increased number of positive COVID-19 cases led the Rosebud Sioux Tribe to also implement checkpoints on tribal land highways. 

In an action of solidarity, a bipartisan group of state lawmakers wrote a letter in support of these tribal actions to Gov. Noem, and they cited the 1851 and 1868 Fort Laramie Treaties, which clarify that the state “has no jurisdiction over the highways running through Indian lands in the state without tribal consent.” Gov. Noem responded by sending a written plea to then President Donald Trump for federal intervention. Citing this plea, U.S. Sens. John Thune and Mike Rounds and U.S. Rep. Dusty Johnson sent a letter to U.S. Interior Secretary David Bernhardt requesting clarification on jurisdiction. The Association for Multicultural Counseling and Development’s Native American Concerns (NAC) group also wrote a position letter in support of tribal sovereignty. In the end, Native sovereignty was maintained, and the decision to have contract tracing checkpoints was applauded. 

This conflict, however, did not end with the unjust challenge over highway checkpoints. As predicted by Chairman Frazier, when members of the Cheyenne River Sioux Tribe and Oglala Sioux Tribe fell ill with COVID-19, they did not have sufficient medical resources to meet the needs of their communities. And despite having available hospital beds in South Dakota, tribal members were forced to seek medical assistance in other states, traveling as far as Denver and Cheyenne, Wyoming. This not-so-subtle form of discrimination led to an Eight Circuit ruling that supported the 1868 Great Sioux Nation Treaty, which requires the United States to provide “competent physician led-health care.” 

A similar discriminatory health care policy occurred at the Lovelace Women’s Hospital in Albuquerque, New Mexico, where pregnant Native American women were singled out for COVID-19 testing based on their race and zip code. In a June 2020 article in ProPublica, Bryant Furlow unveiled that this hospital’s secretive policy resulted in some Pueblo Nation mothers being separated from their newborn babies for up to three days. No other hospital in the area enacted a similar policy for new mothers, and the practice was finally identified and stopped months later. This egregious practice is evocative of the 1860 U.S. cultural genocide policy to separate Native children from their parents and place them in government boarding schools, which ceased in the 1970s. Policies of this nature are reminiscent of historical traumas, and they also create new traumatic experiences and contribute to negative mental health outcomes. 

The financial toll 

The pandemic also severely hurt Native Americans economically when public commerce restrictions led to a significant economic downturn. Many of the revenue streams Native nations rely on are in the hospitality and service sectors, gaming industry and public-driven enterprises, such as the Hualapai Tribe’s Skywalk over the Grand Canyon. Generally, these enterprises were either closed or experienced significant revenue losses during the pandemic, which decreased the economic health of the community-based tribes. 

Although many Americans experienced financial hardship due to the ramifications of the pandemic, the Native American circumstances were compounded due to the intersection of the high percentage of COVID-19 deaths with tribal economic interdependence for survival. According to the 2020 report by the National Center for American Indian Enterprise Development, more than two-thirds of Native-owned businesses suffered significant revenue losses. 

As noted in a 2020 report by the Federal Reserve Bank of Minneapolis, Native American employment had the biggest drop in April 2020 of any racial group. This decrease in employment was also highlighted by Robert Maxim, Randall Akee and Gabriel Sanchez in a 2022 Brookings article that exposes the vast differences in unemployment rates across Native American, Asian American, Black and white populations. In January 2020, the unemployment rate for Native Americans was 7.5%, Black Americans was 6%, Asian Americans was 3%, and white Americans was 3%. In March 2020 the unemployment rate drastically increased, with 28.6% unemployment for Native Americans, 16% for Black Americans, 14% for both Asian Americans and whites Americans. The unemployment rate in January 2022 displayed improvements, with 11.1% unemployment for Native Americans, 8% for Black Americans, and 4% for both Asian Americans and white Americans. The authors of this article acknowledged a prolonged disparity, noting it was the “first time the government published monthly unemployment data on Native Americans.” This former exclusion has had negative effects on economic recovery efforts, supports and research, which was highlighted in a 2022 Journal of Counseling & Development article by NAC members.  In addition, as noted in a 2021 report by the Food Research and Action Center, the pandemic also exasperated food insecurities in a unique way for Native communities, resulting in locations running out of basic supplies at unprecedented rates.

On a positive note, Mark Trahant, in a May 2022 article published in Indian Country Today, noted that members of Congress intended to use a recent U.S. Congress report that detailed persistent structural barriers that have limited economic opportunities within Native communities to inform public policy. The American Rescue Plan’s investment of $31 billion into Indian Country is an attempt to bridge these gaps. The U.S. Congress report highlighted the interconnectedness of economic status and resources in relation to health outcomes. Much is still unknown, including the investment’s impact, yet the hope is that these positive movements can make a tangible difference.

The mental health toll

The loss of multiple family members and tribal elders who were the carriers of traditional knowledge and language can be especially difficult to bear, given the depth and breadth of such cultural information on personal and tribal identity. This can be especially devastating when the elder was the last living person with knowledge that predated the U.S. policy of boarding schools, which systematically removed Native American youth from their families and was an intentional form of cultural genocide.  

These losses were experienced by Native Americans in various geographical areas, including rural, suburban and urban areas, and on reservations. Native clients living in urban areas away from their Native communities, which have suffered great losses, might have faced barriers and restrictions that prevented them from participating in grieving rituals, thus complicating their grief. These clients may have also experienced isolation and disconnection from ceremonies, cultural practices and community support due to limitations caused by the pandemic, adding further emotional challenges. 

Local, state and federal policies that have racial disparities can add exponentially to bio-psycho-socio-spiritual aspects of the presenting problem with severe implications that reach beyond the non-Native pandemic experience. Due to these distressing impacts, practitioners should be aware of the historical trauma that the pandemic has triggered for Native American people who have suffered multigenerationally from U.S. betrayal and a failure to support Native interests. In a November 2021 NPR article, Adrienne Maddux, executive director at Denver Indian Health and Family Services, and Spero Manson, director of the University of Colorado’s Center for American Indian and Alaskan Native Health, shared that the pandemic had heightened

Ruslana Iurchenko/Shutterstock.com

historical trauma and the “sense of pain, suffering of helplessness and hopelessness” for Natives who have endured oppressive circumstances for generations. These observations dovetail with Allyson Kelley and colleagues’ findings in a 2022 article published in the American Indian and Alaska Native Mental Health Research that confirm significantly higher rates of American Indian and Alaska Native (AI/AN) children experiencing orphanhood as a result of the pandemic. 

The shelter-in-place orders and other mandates contributed to disturbances in physical and mental health due to the disruption in social, cultural, and economic practices and norms that are at the core of what it means to identify as a Native American. These circumstances contributed to increased rates of depression, suicidality and other pandemic-related stressors. A post-pandemic poll conducted by NPR, the Robert Wood Foundation and Harvard T.H. Chan School of Public Health found that Native Americans now suffer from increased depression, anxiety, sleep problems, stress and posttraumatic stress disorder. 

Before the pandemic, 50% to 88% of homes on tribal lands lacked internet, broadband and even phone services, so it is easy to see how these disparities elevated difficulties for Native Americans to transition to shelter-in-place orders, virtual opportunities and telemedicine. In a 2022 article published in American Indian and Alaska Native Mental Health Research, Amanda Hunter and colleagues reported that some Native American researchers used funding and advocacy to improve technological infrastructure, yet this help was limited to a few areas. These honorable efforts, however, were not able to mitigate the long-term effects of the technological disparities. 

A 2022 article in Shift Nursing reported that the depression rates for people in North Dakota had risen from 19.2% in 2020 to 33.3% in fall 2021. And of particular concern, the 2019 Fargo Cass Public Health Assessment found “a suicide rate of 45.1 for Native Americans in North Dakota, compared to the national average of 13.4.” This article also highlights access to insurance and costs as barriers to mental health treatment. 

On the positive note, mental health practitioners benefit from knowing that protective cultural factors can serve as a resource for Native American clients. Amanda Hunter and colleagues detailed how the protective factors of community, relationality, abundance, strength and resilience found in AI/AN communities have improved outcomes during the pandemic. These protective factors may exist for Native American clients who are struggling with post-pandemic issues and help them to pave a way forward through their struggles with anxiety, stress and depression. Many Native communities executed resilience during the hardships, disparities, challenges to sovereignty and disruptions to protective factors. Continued mental health support is essential to sustain resilience. 

Clinical considerations

Mental health practitioners demonstrate ethical care by incorporating how the aforementioned tolls affect Native clients while also seeking knowledge and understanding to maintain cultural competency. Counselors can learn more about current events within Native American communities by reading Native news resources such as Indian Country Today, IndianZ and Native News Online. Along similar lines, it is culturally responsible to understand that each tribe has its own culture and to be aware of tribal resources. Here are a few tribal resources that might be helpful depending on location: Northwest Portland Area Indian Health Board, Native Hope, Indigenous Story Studio, One Sky Center, We R Native, Center for Native American Youth at the Aspen Institute, First Nations Development Institute, and Centers for American Indian and Alaska Native Health. More general resources can also be found at the Indian Health Service (an agency under the U.S. Department of Health and Human Services) and SAMHSA’s Tribal Training and Technical Assistance Center websites.

In September, Kristi Taylor-Bond, a nationally certified addictions counselor and a chemical dependency clinical supervisor in Alaska who works with Alaskan Native populations, shared the following description of how the pandemic has affected the Alaska Native community with the NAC group: “COVID has halted in-person gatherings, which are essential to Native communities. It is common for Alaska Native crafters and artists to gather at the Native hospital and other corporation-run locations to sell crafts [and] traditional foods and to visit with friends. With these activities ceasing, many elders have been more isolated and unable to earn income from selling their art. Elders are especially vulnerable to mental health decline when they are not able to connect with loved ones.” This statement reverberates how important it is for counselors to access clients’ understanding of culture and their sense of belonging to culture as well as how disruption from this culture affects mental wellness. 

AI/AN clients benefit when counselors include the following spectrum factors for cultural consideration during sessions:

Connection/disconnection: Explore how AI/AN clients are experiencing connection to their community and cultural practices.

Contributor/burden: Ask AI/AN clients how they perceive their community is experiencing their needs. Does the client see their needs as a burden to others? Is there balance to how the client views their own contribution and needs? 

Collective/isolation: Determine AI/AN clients’ degree of connection to elders. This is important because elders hold wisdom for healing and challenging times.

Balance/imbalance: Guide AI/AN clients to reflect on what is working and explore the balance of wellness from the client’s cultural perspective. 

Cultural responsible therapeutic services also include the method in which counseling is offered. Telehealth is becoming a more widely used modality, so additional considerations are important to keep in mind. Taylor-Bond also shared the following with the NAC group: “While telephonic and video sessions may be a very successful alternative for urban and younger folks, Alaska Native elders and those living in more rural settings are not finding the same success, in my opinion. There is a really beautiful part of building rapport with AN elders that I have found, and that is just being with them. … Lots of the rural kids and adults I’ve worked with first get to know you by experiencing you.”  

SAMHSA and the U.S. Department of Health and Human Services have shared research informing how cultural disruption is a risk factor for suicide and mental illness in AI/AN communities. 

What counselors can do

Policy informs funding and laws, and funding delivers resources to initiate change. Counselors can engage in local and federal advocacy to improve facilities, research, treatment and access. There are many ways counselors can advocate and encourage changes. Understanding how local laws affect mental and behavioral health allows clinicians to discuss the impact and needs of Native American clients and practitioners with legislators. It is essential for counselors to know the systemic barriers that create limitations for Native American clients to obtain mental health care in order to inform elected officials on ways to improve access to these services. Identifying methods to deliver culturally appropriate services will improve the quality of service and access to care. 

When counselors advocate for efficacious culturally appropriate services, policy makers can pass legislation that protects vulnerable communities, builds access to culturally competent services and designates funding to increase equitable services and research. Supporting scholarship through funding is necessary to increase culturally appropriate interventions for therapeutic services. Currently, the funding for AI/AN research is 0.01% of the mental health research budget of the National Institutes of Health. In their article, Hunter and colleagues revealed how the pandemic has disproportionately affected Native communities, and more research is needed to explore the underlying factors and impacts of COVID-19. 

In their 2022 article, Kelley and colleagues shared how communities across Indian Country established policies, adapted services, created education and service delivery strategies, and developed resources to keep individuals and families safe. Many of these communities partnered with federal agencies, including the Centers for Disease Control and Prevention, Federal Emergency Management Agency, and Indian Health Service. 

Advocacy and progress take time and can provide healing to Native American communities. It was not until the passing of the American Indian Religious Freedom Act of 1978 that Native Americans could more freely worship in the United States. In 2021, Deb Haaland became the first Native American to serve in the presidential cabinet as the U.S. Secretary of the Interior. In August, Mary Peltola became the first Alaskan Native elected to the U.S. House of Representatives. In July, more than 1,000 acres of land were returned to the Onondaga Nation in New York, acknowledging them as the original stewards of the land. This recognition allows for healing and restoration as it further emphasizes sovereignty.  There remain numerous injurious land policies fueling advocacy efforts, including the Dakota Access Pipeline and national monuments such as Bears Ears and Grand Staircase-Escalante.

The American Counseling Association began its 2022 Conference & Expo with a land acknowledgment. This acknowledgment is essential in the collective healing process and promotes an understanding of the compounding historical and current trauma many Native people endure in their lived experiences. This understanding provides counselors with a window into how the complex traumas may present in symptomatology and offers insight to healing pathways. It truly takes all of us to create a representative government and institute change to heal and progress together.



AMCD Native American Concerns group

The Native American Concerns group is one of seven focus group for the Association for Multicultural Counseling and Development (AMCD), a division of the American Counseling Association that works to promote ethnic and racial empathy and understanding. AMCD encourages changing attitudes and enhancing understanding of cultural diversity. The Native American Concerns group actively supports Native voices in research and provides advocacy for Native counseling issues. It is a resource and community base for Native counselors and those who serve Native populations. Learn more by visiting multiculturalcounselingdevelopment.org.



Nicola A. Meade is a national certified counselor, a licensed clinical professional counselor in Maryland, a licensed professional counselor in New Jersey, the co-vice president for the AMCD Native American Concerns group, and an assistant professor of counseling and psychology at Georgian Court University. Her extensive work includes serving as a domestic violence advocate for Native women, increasing counselors’ understanding and awareness of Native voices, and researching counselor identity and workplace-based racism. Contact her at nicolaameade@gmail.com. 

Roni K. White is a national certified counselor, a licensed clinical professional counselor in Maryland and a co-vice president of the AMCD Native American Concerns group. She founded Apricity Wellness Counseling, a small private practice in Gaithersburg, Maryland, focusing on trauma, spirituality, minoritized women and relationships. Visit her at apricitywellness.com. 

Carol ZA McGinnis is a certified spiritually integrated psychotherapist, a board-certified telemental health practitioner, a national certified counselor, a licensed clinical professional counselor in Maryland and a current member of the AMCD Native American Concerns group. She is an associate professor of counseling in the graduate counseling department at Messiah University. Her research interests include functional anger, spirituality in counseling, and Xbox video gaming. To learn more, visit www.anger.works.


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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.

Building resilience in children after a pandemic

By Celine Cluff October 13, 2022

A lot has changed for adults and children since the onset of the COVID-19 pandemic. People’s social and work lives have been turned upside down. Children had to unlearn the behavior to touch and explore the world around them, and with an overall uptick in anxiety, they have also had to learn to cope with increased stress levels in their environments. The toll that this has taken on youth remains to be explored.

Psychological resilience represents the ability to mentally or emotionally cope with a crisis or to return to the original precrisis status. According to the research of Michael Ungar, founder and director of the Resilience Research Centre at Dalhousie University, and Kristin Hadfield, an assistant professor of psychology at the Trinity College Dublin, factors that improve a young person’s life change depending on whether they live in a community that is stable and safe or one that presents them with a challenging environment. This means that we have to pay attention to a child’s environment to understand what factors help them build resilience. COVID has certainly had a negative effect on peoples’ environments, and it may have even caused surroundings that were stable and safe to turn into ones that are not.

With the implementation of four simple steps, the connection and trust between children and caregivers can be strengthened, which, in turn, can lead to the mitigation of some of that angst still lingering from the pandemic.

Step 1: Have a conversation during a meal. Dinners are a great proxy for connecting. At a minimum, sharing a meal serves as a way to catch up and reconnect. Admittedly, dinners with young children don’t tend to last long, but often a quick check-in will suffice if done regularly as a part of a daily routine. For example, a family could set an egg timer for ten minutes of “family time” and then take turns talking about their “rose and thorn” of the day; the rose is something positive that happened that day, and the thorn represents something less desirable that may have occurred. This exercise works to strengthen the interpersonal connections between family members and helps them stay on top of things that require attention that may otherwise slip through the cracks.

Step 2: Teach choice-based behavior. Caregivers can boost confidence levels in children by inviting them to practice autonomy. A simply way to do this is for a caregiver to offer the child options when they want them to do their chores or help around the house. For example, if the caregiver wants the child to help with dinner, they could say, “It is your turn to set the table for dinner. You can do this now, or you can choose to clear the table after dinner instead but you’ll have to load the dishwasher too.” Caregivers can also discuss and acknowledge how important their contribution is. Praising the child for accomplishing the task and letting them know that their help is valued delivers a confidence boost and strengthens the connection to their caregiver. After all, everyone appreciates being valued for their efforts!

Step 3: Teach initiative taking. Initiative taking — completing a task or chore without being prompted to do so — is a skill that can be taught. The most effective way to encourage this independent behavior is to model it, encourage it through positive reinforcement and let it happen organically. Sometimes this means biting one’s tongue instead of telling the child to stop doing what they are doing (if what they are doing is safe). Initiative taking is a skill that can be developed in early childhood and will serve children well into their adult years. It promotes a sense of self-worth by making children feel capable to make decisions and execute tasks. Letting children explore what they are capable of in a safe environment can boost confidence and encourage independent behavior down the road.

Step 4: Be present. Children have a universal talent for demanding attention. Sometimes, it is possible to give them the attention they crave and other times it’s not. Here’s a common scenario: A child demands attention when their caregiver is in the middle of something that requires their neurons to fire at full capacity. Although it may seem daunting, taking one minute out of their busy work schedule to make eye contact with the child and hear them speak will not negatively affect productivity levels or work outcomes. But what it will do is show the child that they are valued and heard, which boosts their confidence. In addition, modeling good listening skills will strengthen the caregiver-child bond and will help to ensure continuous respectful exchanges in future interactions.


In summary, a resilient child will have at least one continuous, resilient interpersonal relationship with a parent, caregiver, close relative or even friend. Nurturing these relationships plays a pivotal role in the maturation of a child’s psychosocial development. The four steps mentioned previously are suggestions on how to nurture these connections. Research from the realm of positive psychology continues to underscore the mental health benefits of having fulfilling interpersonal relationships. According to Mark Holder, a psychological researcher and former associate professor at the University of British Columbia, nurturing interpersonal relationships also contributes to people’s happiness, and it is the quality, not the quantity, of the relationships that brings people the most joy.

The concept of increasing happiness levels by nurturing interpersonal relationships also applies when children interact with other children. It is important to let children engage with each other on their own terms (interfering only if necessary), enjoy outdoor playtime, act out different scenarios with peers (e.g., playing cops and robbers, which is a variation of tag) or simply enjoy the company of like-minded youth. Children’s social and emotional repertoires are developed during these early years. Although extracurricular activities are also valuable, they cannot replace the social/interpersonal exchange in early childhood development. It is important to keep in mind the need for both when raising resilient kids.

In their research, Ungar and Hadfield emphasize people’s social ecologies (or preservation thereof) when it comes to their development and level of resilience during times of crisis. Because creating a stable and safe environment plays a pivotal role in laying the groundwork for this development, staying open minded about ways to parent during times of crisis is also important. A simple exchange about what the caregiver’s day was like or how they are feeling (happy, sad, etc.) will often go a long way. It is always a pleasant surprise to learn how much children can give in return if they are shown that adults are vulnerable too.



Celine Cluff

Celine Cluff is a registered clinical counselor practicing in Kelowna, British Columbia, Canada. She holds a master’s degree in psychoanalytic studies from Middlesex University in London and recently completed her doctorate in psychology at Adler University in Chicago. Her private practice focuses on family therapy, couples therapy and parenting challenges. Contact her at celine.cluff@yahoo.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.

Voice of Experience: Our new world

By Gregory K. Moffatt July 18, 2022

I’d like to say we are in a post-pandemic world, but I know that isn’t exactly true yet. Even so, I can’t believe how much our world has changed in the past three years.

The lockdowns, mask requirements and financial issues of the COVID-19 pandemic, to name a few, added stressors to our world that I have never seen in my lifetime.

I am a college professor and some of my students finished their third year of college never having seen a classroom without masks, screenings, quarantines and other precautions brought on by the pandemic. My wife teaches 4-year-old prekindergarten, and some of her former students from three years ago, who are now going to the second grade, have never seen their teachers’ faces unmasked.

The pandemic also magnified mental health and social problems that were already present, including addictions, anxiety, depression, marital discord and a host of other issues. The last thing my clients struggling with addictions or depression needed was to be locked down at home for weeks on end with nothing to do. That doesn’t even begin to touch the magnitude of clients with obsessive-compulsive disorder who struggle with the fear of germs or autistic spectrum clients who need routines.

A few months ago, I wrote in my column that burnout could be managed, at least sometimes, by reframing. One reader criticized that statement by noting that the pandemic has been so overwhelming that reframing isn’t a panacea. I can’t argue with that criticism. This situation is just so different, I suppose.

For over a year, I didn’t eat out and I found myself anxious every time I wanted to go to a store. I’d wonder if it was open, if they had the items I needed and what restrictions they might have. I found it easier to just stay home.

Like all of you, I’ve shared the stress of relatives who worked in jobs that couldn’t easily be done remotely, especially in the retail and the restaurant industry. I saw some of them lose their financial stability and some even lost their jobs, which only added stress to the other preexisting stressors.

Most of us have been affected by this pandemic in one way or another. So many of us have been sick. Nearly all my family has had it, including me, despite vaccinations. And then, of course, there is death. Like others, I lost a close friend to this virus.

This doesn’t even include the political and social divisiveness surrounding issues related to this pandemic. Families have been divided — maybe even permanently — over the question of vaccines and boosters.

People are seeking help from counselors in numbers I’ve never seen before. I don’t know a single counselor who isn’t operating on a full schedule right now, and it has been that way for months.

But the pandemic has caused us to grow as well. Three or more years ago, most counselors didn’t do telemental health. Even though I had the credentials for telehealth as well as telesupervision, I rarely used it before the pandemic. But now, I don’t even accept an intern who hasn’t had telehealth training. It wasn’t even on my radar three years ago to require telehealth training for an intern, and I don’t know of any graduate programs that required or even offered it.

I’ve also grown to appreciate telehealth as a client. Because I live in a rural area, I’ve always had a hard time finding my own therapist who wasn’t 50 miles away in Atlanta. Now, I can manage my self-care in a one-hour telehealth session rather than spending three or four hours driving to and from my therapist’s office in Atlanta.

We’ve seen changes in continuing education requirements as well. In my state, prior to the pandemic, only 12 hours of distance learning could be counted for recertification. Now nearly all of them can be as long as they are synchronous — a term that few of us even knew three years ago.

In addition, telesupervision hours now count toward license requirements in Georgia. This gives clinicians in remote areas options for training far beyond what they could have accessed three years ago.

I often wonder why I wasn’t offering my clients the option of telehealth before the pandemic. I had clients who drove two to three hours one way to see me. Why hadn’t I thought to help them by offering distance work? Today, although my caseload with children is still largely in person, I use distance counseling with nearly all my other clients and supervisees.

As we come out of these troubling pandemic years, it is clear we will never be the same. But telehealth has been a positive change for the counseling field and offers a silver lining in the new post-pandemic world.




Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.


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