Tag Archives: interdisciplinary

Counseling people who stutter

By Chad M. Yates, Karissa Colbrunn and Dan Hudock April 11, 2018

Kyle hears the drone of the elevator music playing behind the bland voice that states, “All calls are important to us. Thank you for your patience. A customer service representative will be with you in just a moment.” Kyle knows the message well because he has been on hold for nearly 15 minutes. While waiting, Kyle practices in his head the message he needs to state: “Hello, my name is Kyle, and I need to schedule a shuttle ride to and from the airport.”

Suddenly, a crackling voice replaces the music. “Hello, thank you for calling OK Shuttle. How can I assist you?”

Kyle feels his throat tighten and his chest begin to seize. “Hello, my name is Kyyyyyy, my name is Kyyyyyyy, Kyyyy.”

“Sir, are you there? Sir, are you there?” insists the customer service rep.

Kyle continues: “Hello, my name is Kyyyyle. I need to schedddddd … I need to schedddddd, scheddddd.”

“Sorry, sir,” the voice on the other line says. “We have a poor connection. Please call back again when your service is more reliable.”

The sound of the click thunders in Kyle’s ear as a tight-pitched squeal replaces the silence. Kyle looks down at his feet, too afraid to pick them up and move. He feels frozen in anger, disgust and helplessness. Fear precludes the idea of calling back again.

This experience is all too common for people who stutter (PWS). For these individuals, the experience of communication, which many of us take for granted, becomes a blockade that stands between connection, understanding and the navigation of one’s world.

Experts in the field of speech-language pathology define stuttering as a communication disorder involving disruptions, or disfluencies, in an individual’s speech. The cause of stuttering is typically thought to be a neurological condition that interferes with the production of speech. Although many children spontaneously recover from stuttering, for approximately 3 million U.S. adults (about 1 percent of the population), stuttering is chronic and has no cure. Despite this, there are ways to manage stuttering in both the behavioral sense (how much the person stutters) and the psychological sense (how much stuttering impacts the person’s life).

Situations such as the one that Kyle experienced can happen almost daily for PWS. The pain of these experiences often leads these individuals to isolate themselves from the things they love to do because the risk of communicating can feel as if it outweighs the benefits of living the life they want to live. Peer reactions to unusual speaking patterns can begin as early as age 4. These reactions persist and increase throughout adolescence, which can negatively affect many facets of life, including social relationships, emotional well-being and academic performance, for PWS. Adults who stutter have scored significantly lower in questionnaires regarding quality of life, specifically in regard to vitality, social functioning, emotional role functioning and mental health. Although various studies show that counseling is indicated with this population, many speech-language pathologists are not trained in counseling or do not feel comfortable with their counseling skills and abilities.

Interprofessional collaborations between speech-language pathologists and counselors can be considered best practice for helping PWS and other individuals with common communication disorders. Idaho State University’s counseling and speech-language pathology departments are involved in a unique relationship in which they are training both speech-pathology interns and counseling interns to work side by side to treat PWS. This treatment is provided through the university’s Northwest Center for Fluency Disorders Interprofessional Intensive Stuttering Clinic (NWCFD-IISC), which offers a two-week clinic for adolescents and adults who stutter.

The clinic is the first of its kind in which speech-language pathologists and counseling interns work together to treat the holistic needs of clients who stutter through acceptance and commitment therapy (ACT), a mindfulness-based mental health approach. We (the authors of this article) have conducted the clinic over four consecutive years. Through this experience, we feel that we can share recommendations for counselors working with PWS and with other clients who present with communication disorders. Additionally, we have observed key ingredients for interprofessional collaboration and can speak to strategies to build effective interprofessional teams.

Recommendations for counselors

To be effective working with PWS, counselors need to address the misconceptions they have about stuttering. Consulting resources, such as the National Stuttering Association and the Stuttering Foundation, that are supported by PWS can help counselors to debunk common myths associated with this population.

One common myth is that stress causes a person to stutter. Another myth is that taking deep breaths before one speaks can eliminate stuttering. We have heard countless “cures” for stuttering from the general public. These include placing spices under one’s tongue, receiving acupuncture and sitting or standing with the correct posture. These erroneous cures can be insulting and demeaning to PWS. At best, it is frustrating for PWS to hear these ideas repeated over and over again. Counselors should be knowledgeable about the lack of support for these types of cures while being able to point out to clients resources on effective treatments.

For PWS, reactions from listeners often can be painful. As PWS become more aware of their stuttering and encounter negative listener reactions to their disfluencies, they may develop negative emotions toward communication situations and begin to avoid speaking. The shame and guilt that PWS often feel for stuttering can lead to fear, anxiety and tension in relation to communication, as well as decreased self-confidence. PWS may develop secondary behaviors that they employ in hopes of alleviating their stuttering. These secondary behaviors might include avoiding eye contact, avoiding speaking to people in positions of authority and avoiding certain words that they anticipate stuttering. Being aware of this, it is important for counselors to understand the role that positive regard, expressed behaviorally through continuous eye contact or not averting their glance when PWS speak, can have on these individuals.

Working effectively with PWS also involves using positive and respectful communication practices. During conversations, time pressure can be present when PWS take longer to communicate. This can sometimes lead to one party attempting to finish the other’s sentences. To PWS, this behavior can suggest that their communication of ideas may not be as important as the other speaker’s time.

Finishing a person’s sentences is often done in reaction to uncomfortable feelings associated with the time pressure of communication. Counselors should be aware of when they are experiencing these feelings. They should continue to allow their clients who stutter to finish what they wish to say regardless of time pressure and regardless of whether these clients are having blocks (when sound or air is stopped in the lungs, throat or mouth/lips/tongue), breaking off speech or having repetitions (repeating a sound, syllable or word more than once or twice).

The final recommendation involves the use of person-first language. Often, PWS call themselves “stutterers.” Reframing the language to say a “person who stutters” can reduce the stigma that surrounds the word “stutterer.” This action also treats the person as an individual. During the NWCFD-IISC, we empower PWS and work to mitigate stigma by reinforcing the idea that what a person says is more valuable and important than the way he or she says it. We also affirm that all individuals deserve to communicate their thoughts and ideas.

Recommendations for interprofessional teams

Interprofessional teams can be difficult to start and maintain in practice. Professional training often maintains solo practice as its modality, adding topics related to interprofessional collaboration as elective practice. We have used the stuttering clinic as a way to train counseling and speech-language interns in interprofessional practice and application.

We have observed that to effectively build these teams, it is essential to train our interns on the respective scopes of clinical practice, professional roles and clinical responsibilities of each other’s professions. We also train our students on how to work in teams, how to build relationships based on open communication and respect, and how to understand and use team dynamics that occur during practice. Finally, we reinforce the shared values of both professions — that the well-being of the client is paramount to the purpose of the team.

We have observed that interns typically begin collaborations with thicker boundaries of professional practice and rigid time sharing when interacting with clients. However, after the pair begin to find comfort and understanding of each other’s professional roles, these boundaries begin to wane. Time sharing becomes much more dynamic and less rigid. When intern pairings are working effectively, we see the pair begin to assist each other in their roles and to plan out how they can work together to assist the client during the next session.

To facilitate the interns working together, we teach them specific strategies that are unique to each profession. For example, the speech-language interns learn how to use basic listening skills and practice these skills with the help of their counseling partners. Speech-language interns also learn the foundations of counseling interventions. Specific to the NWCFD-IISC, the interns learn the foundations of ACT. All interns are also taught the practice of meditation and mindful practice, and the principles of acceptance, thought defusion and emotional expansion. Counseling interns learn the foundations of speech-language pathology interventions. Specific to the NWCFD-IISC, they learn about how stuttering occurs, how to assess for stuttering and the social and emotional impacts of stuttering.

All interns in the clinic engage in pseudo-stuttering (fake stuttering) in public and use speech-modification techniques with all clinic participants and the public. Pseudo-stuttering can be used as a therapeutic strategy for PWS to increase acceptance and openness with their stuttering and to increase self-confidence. When the clinic interns pseudo-stuttered and used speech-modification techniques with NWCFD-IISC clients in public, the clients reported that these experiences strengthened the client-clinician relationship.

Our recommendation to counselors and speech-language pathologists who desire to develop collaborative teams is to be intentional about building a professional relationship on the grounds of respect and open communication. The team members should take time to learn about one another’s professions, roles and clinical responsibilities. We have observed during the training of our interns that speech-language pathologists are often focused on outcomes and data collection, whereas counselors are often more focused on process elements and the clinical relationship. It is essential to see both sides of the team as contributing to the overall impact in a unique way. The team members will work to support one another’s strengths and weaknesses.

Counseling interventions

The NWCFD-IISC uses an ACT framework. ACT was chosen because it provides a strengths- and skills-based approach grounded in mindfulness and psychological flexibility. ACT explores human suffering as it relates to psychological inflexibility. Using this framework, PWS learn to more fully focus on the present moment, become more accepting of their thoughts and feelings, and take steps toward acting in alliance with their personal values.

Several studies have supported positive results regarding the efficacy of ACT when applied to stuttering. In addition to this supported efficacy, we think that ACT closely aligns with the philosophy of the NWCFD-IISC. Our philosophy of treatment involves clients and students taking a team approach to understand, accept and effectively manage thoughts, emotions and behaviors related to stuttering. This is accomplished through generalized experiential activities, group education and discussion, and individual and group counseling.

ACT can be understood through the six guiding principles on the ACT hexaflex. These six principles are acceptance, thought defusion, mindfulness, self as context, values and committed action. Investigating how each principle applies, we can begin to understand the process of counseling PWS through an ACT lens.

1) Mindfulness: Clients who stutter often avoid the present moment by judgmentally reviewing the past or worrying about the future. Clinicians can help PWS to connect with the present moment through the use of meditation and mindfulness activities. Encouraging mindful practices can be a goal to incorporate in counseling.

2) Acceptance: PWS often feel like they have no control over their stuttering. Regardless of what they do, a stuttering moment may or may not arise. In these moments, PWS can choose to talk, choose to stutter openly and choose to acknowledge all the thoughts and emotions related to stuttering. Clinicians can help PWS explore acceptance of their thoughts and feelings. PWS do not need to like the thoughts or emotions they experience or enjoy stuttering. However, they can experience their thoughts or emotions as they surface without judgment.

3) Thought defusion: PWS have a tendency to overidentify with their thoughts or feelings, enabling these thoughts and feelings to become mental truths that cause inflexibility within the thought process. PWS may attempt to mentally avoid stuttering or become overwhelmed trying to control their speech. Additionally, PWS may feel certain that other people will reject or harshly criticize them, thus causing them to avoid social contact.

Clinicians can help PWS to explore and express all thoughts — helpful and unhelpful — about their stuttering. By unhooking from the thought or emotion, PWS can experience more psychological flexibility in relation to the context that the thought or emotion is occurring within.

4) Self as context: Individuals often associate with expressions in the form of labels, such as “I am smart” or “I am dumb.” These labels relate to content, not context. Individuals may define themselves in terms of content instead of context to fuse with thoughts and emotions that may be either known or unknown. PWS use self-as-content behaviors to avoid facing the reality of stuttering. PWS may think, “I stutter. That’s all I do. Because of my stuttering, I do poorly in school and never meet new people.”

Clinicians should explore with PWS how these thoughts about self are related either to content or context. Reinforcing flexibility in self-identity is key because it allows PWS to adapt more flexibly to novel situations.

5) Defining values: As described by Jason Luoma, Steven Hayes and Robyn Walser, in ACT, values are defined as “constructed, global, desired and chosen life directions” that can be expressed as adverbs or verbs. When exploring values with PWS, the notion of choice is important to discuss. Choice connotes the flexibility and autonomy they possess in defining what guides their behaviors or life direction.

A common values activity involves the “eulogy exercise.” During this activity, PWS visualize what a close friend would say at their funeral. Clinicians might even direct PWS to write down the values that were expressed during the eulogy: “He was a kind person” or “She was a caring friend” or “He was a compassionate individual.” Clinicians can then discuss these values with PWS and explore how these values are currently manifested and how they can become lost. Building awareness of what values are important in a person’s life can encourage these clients to persist through the difficult times they face.

6) Committed actions: ACT explores the concept of choice in alignment with values-based goals. When clients feel ready to initiate steps either within or outside of counseling, exploration of these committed actions in the counseling session is warranted. For PWS, committed actions could be used by encouraging challenging stuttering situations. For example, PWS may choose to take action directed at speaking situations during dating, during novel social interactions or within work settings. Committed action is the stage of counseling that encourages the synthesis of the tools within the complete hexaflex. PWS learn to engage in a way that is adaptive and flexible to their external and internal worlds.


Counseling PWS can be a rich and rewarding experience. Through our work in the NWCFD-IISC, we have built lasting connections with individuals in the stuttering community and learned how to form strong interprofessional teams that enhanced our understanding of two professions. In working with PWS, understanding the specific population concerns is key to effective treatment. Additionally, collaboration with professionals in the speech-pathology discipline can further enhance treatment experiences for PWS and for all professionals engaged in the collaboration.




Chad M. Yates is a licensed professional counselor and an assistant professor in the Idaho State University (ISU) Department of Counseling. He has served as the mental health coordinator for the Northwest Center for Fluency Disorders at ISU for several years. He helped to develop the acceptance and commitment therapy (ACT) manuals and procedures for clients and clinicians at the clinic and supervises the counselors providing ACT. Contact him at yatechad@isu.edu.

Karissa Colbrunn is a school-based speech-language pathologist in Pocatello, Idaho. She is passionate about merging the values of the stuttering community with the field of speech-language pathology.

Dan Hudock is an associate professor at ISU. As a person who stutters, he is passionate about helping those with fluency disorders. One aspect of his research involves exploring effective collaborations between speech-language pathologists and mental health professionals for the treatment of people who stutter. He is the director of the Northwest Center for Fluency Disorders. For information about research, clinical or support opportunities, visit northwestfluency.org.

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The counselor’s role in assessing and treating medical symptoms and diagnoses

By Jori A. Berger-Greenstein April 4, 2018

Take a moment to imagine the following scene, with you as the protagonist: A few days ago, you woke, went for a run, had breakfast and headed to work, where you attended a committee meeting. The next thing you remember is lying in a hospital bed and being told that you had a stroke. You seem unable to move or feel one of your legs.

You are in a double room with an elderly man who has had many relatives and friends visit, although he seems not to be doing well. You’re not sure, however, because you feel foggy. Is this a side effect of the medication they keep giving you?

You are dressed in a hospital johnny and confined to bed. A nurse checks your vital signs on the hour, often waking you when you’re sleeping. An intravenous tube in your arm is connected to a bag with some sort of liquid in it, and you are hooked up to monitors, although you’re uncertain of what they are monitoring. Beepers sound regularly, prompting the nurses to come check you, look at the monitors or change out the bag.

A doctor visits in the mornings, along with a group of medical students, reminding you of Grey’s Anatomy, complete with looks back and forth and eye-rolling. They talk among themselves as if you aren’t there, using medical jargon that you don’t understand. Your family members are anxious and tearful. You hear them talking to the doctor about transferring you to another facility because your insurance won’t continue to cover your stay in the hospital. You also hear your spouse on the phone with relatives who live across the country but want to come see you.

As the patient, how might you be feeling? What might you be thinking?

Now imagine that instead of being the patient, you are a mental health provider called in to assess the patient for depression. How might you respond?

The above scenario and others similar to it are commonplace for many providers who operate in the field of behavioral medicine, which the Society of Behavioral Medicine defines as the “interdisciplinary field concerned with the development and integration of behavioral, psychosocial and biomedical science knowledge and techniques relevant to the understanding of health and illness, and the application of this knowledge and these techniques to prevention, diagnosis, treatment and rehabilitation.”

As recognition of the psychological and behavioral factors involved in medical illness has increased, so has our ability as mental health counselors to serve a valuable function in patient care. Providers and researchers alike now recognize the importance of approaching health care more holistically rather than compartmentalizing medical versus psychological well-being.

Understanding context

Primary care providers, the first stop for most people’s health-related complaints, operate under ever-increasing pressures to provide care for more people in less time. The average visit lasts 10 to 15 minutes, with the goal of assessing presenting symptoms (typically while simultaneously entering patient information into a computer system) to ascertain their cause and thereby provide information about how to treat them. There often isn’t time to gather the context of these symptoms, increasing the likelihood that important details can be missed. Likewise, there isn’t sufficient time to fully discuss the pros and cons of treatment options, the potential barriers to treatment and whether a patient is willing or able to follow through on the treatment recommendations.

In contrast, mental health providers often have the luxury of coming to understand patients/clients more fully. This includes understanding and appreciating the contexts in which patients/clients find themselves, understanding how these individuals are coping and making meaning of what is happening, and forming a trusting relationship with them, which is consistently demonstrated to be predictive of adherence to care and improvements in health-related parameters.

As Thomas Sequist, assistant professor of health care policy at Harvard Medical School, stated in a New York Times article in 2008, “It isn’t that [medical] providers are doing different things for different patients, it’s that we’re doing the same thing for every patient and not accounting for individual needs.”

It can be said that medical providers are trained to identify and treat symptoms in order to identify disease so that a patient can be effectively treated — which is, in fact, their role. In contrast, mental health providers are trained to treat people and illness — illness being one’s experience of disease rather than just a compilation of symptoms or diagnostic labels.

The process of assessing for mental health symptoms

A variety of mental health conditions are characterized by symptoms that overlap with those attributable to medical conditions. For example, symptoms of an overactive or underactive thyroid mimic anxiety and depression, respectively. Psychosis can mimic neurological conditions, mood disorders can mimic endocrine disease, anxiety can mimic cardiac dysfunction and so on.

Through training mental health clinicians to identify symptoms that may indicate a medical cause and knowing how to assess for the possibility of a medical workup, we can make earlier referrals for medical care. This, in turn, helps us to identify diagnoses more quickly, leading to easier/more efficacious treatment and better validating concerns.

One’s cultural identity and the resonance of cultural norms are also important to assess and monitor. For instance, a patient may be reluctant to engage with an English-speaking provider, may have a vastly different conceptualization of illness as punishment (in stark contrast to the Westernized biopsychosocial model) and may need validation for his or her reliance on faith and spirituality.


Collaborating as mental health clinicians directly with medical professionals toward the common goal of helping those who need our care can be invaluable. Examples include ruling out mental health disorders, identifying appropriate treatments in the case of comorbidities, providing emotional support to patients who have been diagnosed with a medical disorder and supporting physicians who may be overwhelmed. For instance, medical treaters may not know or understand the presentation of symptoms associated with trauma or the intricacies of providing trauma-informed care.

Being knowledgeable as mental health clinicians about medical-related symptoms, the language and jargon of medicine, and strategies for navigating the medical system provides us with critical credibility. This credibility can make or break our ability to collaborate as mental health clinicians.

Providing care

At its best, behavioral medicine functions as a prevention-focused model with three levels of care:

1) Primary prevention refers to preventing a problem from emerging to begin with. Examples of this might be establishing obesity prevention programs in public schools for young children or working with high-risk families to promote safety practices. The idea is to work with groups that may be more vulnerable to risks at some point in the future and to prevent those outcomes from occurring.

2) Secondary prevention involves working with people who have developed a problem of some sort, with the goal of preventing it from worsening or becoming a larger problem. Examples include working with people who are prehypertensive in order to prevent hypertension and subsequent cardiovascular disease or stroke, and working with people with HIV to increase their adherence to antiretroviral medication to reduce viral load, making them less infectious to others and providing them with more healthy years of life.

3) Tertiary prevention refers to helping people manage an already-existing disease. This might involve increasing quality of life for people enduring a condition that won’t improve, such as a spinal cord injury, multiple sclerosis or late-stage renal disease, and supporting people in the later stages of a disease that is imminently terminal.

Transtheoretical model (stages of change)

Although mental health clinicians may be familiar with efficacious interventions for a given condition, we may not be perceived as credible if we do not understand and respect the client’s/patient’s motivation. No mental health provider’s repertoire is complete without an understanding of the transtheoretical model and how to utilize it to increase an individual’s motivation for positive change.

Assessing where a client/patient might be in the stages of this model (precontemplation, contemplation, preparation, action, maintenance) helps us to better target our interventions in a respectful way by taking context into consideration. Clients/patients in the precontemplation stage might benefit most from education and are less likely to be receptive to recommendations for lifestyle changes, whereas those in the action stage may not need as much of an emphasis on motivation. For a thorough description of the transtheoretical model, I would refer readers to William Miller and Stephen Rollnick’s seminal work, Motivational Interviewing: Helping People Change.

Concrete needs and specific skills

The majority of causes of death and disability in the United States are those caused or treated, at least in part, by behavior. Nationally, the top 10 causes of death, according to the Centers for Disease Control and Prevention (2015), include cardiovascular and cerebrovascular disease, cancer, pulmonary disease, unintentional injuries, diabetes, Alzheimer’s disease and suicide. Changes in lifestyle, knowledge/education and interpersonal support can be successfully utilized as part of all three levels of prevention. In fact, these are areas in which mental health providers can be extremely valuable.

Primary prevention: Data suggest that the single most preventable cause of death is tobacco use, which can dramatically increase the risk of developing cancer, pulmonary disease and cardiovascular disease. Comprehensive smoking-cessation programs can be quite effective in managing this, as can education to prevent young people from initiating cigarette use.

Sedentary behavior (and, to a lesser extent, lack of exercise) is also strongly associated with health problems, perhaps most commonly cardiovascular disease and cancer. Concrete strategies for introducing nonsedentary behaviors (using the stairs, standing up once an hour, walking) can be incorporated into one’s lifestyle with less effort than a complex exercise regimen.

Getting proper nutrition, practicing good dental hygiene and consistently wearing sunscreen, helmets and seat belts are other examples of primary prevention in behavioral medicine. Motivating people who have not (yet) experienced the negative consequences of their risk behaviors is an approach that mental health providers are trained to provide.

Secondary prevention: The rates of obesity have risen dramatically in the past decade and are associated with a wide variety of serious medical complications, including diabetes, cardiovascular disease, stroke and cancer. If treated effectively, the risk of such complications can be reduced significantly. Examples of interventions found to be useful include aerobic exercise, dietary change (such as adhering to a Mediterranean diet and managing portions) and monitoring weight loss.

Although the specifics of these interventions may be most appropriately prescribed by dietitians and physical therapists, mental health providers can add value by helping to increase clients’/patients’ motivation and adherence, providing more thorough education about recommendations and collaborating with other providers.

Tertiary prevention: Spinal cord injury, most often caused by motor vehicle accidents, falls or violence, can have a devastating effect on a person’s life. These injuries are not reversible, but mental health providers can prove valuable in tertiary prevention efforts. These efforts might involve providing existential support; helping patients to navigate the medical system and ask for/receive support from significant others; and identifying strategies for improving quality of life and accessing tangible resources to sustain some aspects of independence.

Getting started

So, how might clinical mental health counselors “break into” the system? The ideal is an integrated care model in which mental health providers are colocated within the medical setting. This serves a dual function of facilitating mental health referrals and making it easier for patients/clients to see us because we’re just down the hall or up a flight of stairs from the medical providers. It also ensures that we remain visible to medical providers and allows for us to easily demonstrate our value.

Short of this, and for those who are less interested in focused work in behavioral medicine, the following suggestions may be helpful:

1) Attend trainings. This is a crucial first step before mental health counselors can ethically market themselves as being knowledgeable about behavioral medicine. As an example, with rates of diabetes increasing, and associated adjustment and psychological sequelae common, learning all you can about the disease and strategies for managing it provides you with some expertise and a valuable referral option. This is consistent with current recommendations for branding a practice.

2) Develop a niche. Your services can be all the more compelling if you have developed a niche for yourself that fills a gap. Research your area and the specialties that mental health providers are marketing. Is there something missing? For instance, many providers may be offering care for people who are terminally ill, but are there providers specializing in working with young people in this situation? Are people who specialize in working with pediatric cancer also advertising services to treat siblings or affected parents?

3) Being mindful of your competence and expertise, connect with medical providers and let them know that you are accepting clients. For instance, if you work with children or adolescents, consider reaching out to pediatricians. Research consistently finds that the only linkage to care someone with mental illness may have is through his or her primary care physician. Providing these physicians with literature about your services makes it easy for them to pass along your information to anyone they think may benefit. Mental health counselors can connect with medical providers via personal visits to physicians’ offices or through direct marketing to professional organizations. Note that approaching small practices may be the better option because they are less likely to already be linked with another service (hospitals often have their own behavioral health clinics/providers).

4) Connect with specialty care providers. These providers tend to have greater need of mental health professionals who are familiar with a given diagnosis.

5) Don’t be afraid to contact a medical provider treating one of your clients. This can provide a means for collaborative care and could also serve to gain you credibility, while indicating that you are glad to take referrals. Clearly, this should be done only if clinically indicated and only with the client’s permission.

6) Finally, be prepared to describe your experience, training and competency areas in a brief fashion. In the busy world of medicine, time is quite valuable. Mental health providers’ skills in waxing poetic can get in the way of communicating the essence of what we want to get across.


This article would be incomplete without a mention of ethics. Behavioral medicine is a field rife with ethical concerns. Perhaps the most salient of these is competence. From an ethical lens, it is critical that we, as mental health counselors, recognize the limits of our competencies — that is, we are not trained in medicine and thus cannot ethically diagnose a medical condition, recommend treatments that could be potentially harmful or assure patients/clients that medical evaluations or treatments are unnecessary. All of these actions require the input and monitoring of medical treaters, who can guide our efforts in care. Patients/clients also need to be clearly informed of both our benefits to and limitations in their care. The world of medicine changes rapidly, and the half-life of training in medicine and medical care is short. Ongoing education is critical.

Let’s return to the scenario described at the beginning of this article. The shared goal for all providers — medical, psychological and other — is to provide efficacious and meaningful care in a way that improves the patient’s health and quality of life. By utilizing our respective areas of training, competencies and strengths, we can better understand the context of symptoms, which can guide our care. This is the cornerstone of providing ethical care.




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

Jori A. Berger-Greenstein is an assistant professor at the Boston University School of Medicine and a faculty member in the mental health counseling and behavioral medicine program. She is an outpatient provider in adult behavioral health at Boston Medical Center, where she serves on the hospital’s clinical ethics committee. She also maintains a private practice. Contact her at jberger@bu.edu.

Letters to the editorct@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.

Adding a counselor’s voice to law enforcement work

By Bethany Bray March 17, 2016

For Gregory Moffatt, counseling and crime solving go hand in hand.

Moffatt, a licensed professional counselor (LPC), runs a private practice in which he specializes in working with children who have experienced physical or sexual abuse. He is also a professor of counseling at Point University in West Point, Georgia.

The other half of his career, however, is a little more unconventional. He’s a risk assessment and psychological consultant for businesses, schools and law enforcement agencies. Moffatt has done everything from assisting with hostage situations and unsolved cold case investigations to teaching at the FBI National Academy in Quantico, Virginia. In addition to providing training and consultation, he evaluates police officers who have been involved in a duty-related shooting to determine if they’re ready to return to active work on the force.

He’s also filming on-camera commentary as a psychological consultant for a new cable television show on hostage situations. The program, titled “Deadly Demands,” premiers March 21 on Investigation Discovery, a network of the Discovery Channel.

After years of working with corporations and law enforcement agencies, Moffatt is often the person they call to evaluate unusual situations, such as when an employee is making co-workers uneasy or

Gregory Moffatt, LPC and professor of counseling at Point University in West Point, Georgia

Gregory Moffatt, LPC and professor of counseling at Point University

a case arises that doesn’t fit the norm. It’s not a niche that he initially set out to carve for himself, but rather one that he entered “through the back door,” he says.

When Moffatt first started teaching at Point University more than three decades ago, he was the only professional counselor on campus. One day, the university’s administration approached him and asked for his help with a situation involving a student who was stalking another student.

“Stalking laws weren’t in place. Back then, even the term [stalking] wasn’t an everyday term,” says Moffatt, an American Counseling Association member. “Back then, hardly anyone did work in violence risk assessment.”

As he got involved in the case, Moffatt started researching risk assessment methods, which grew into a personal area of interest. He eventually established his own consulting business, through which he provides workplace violence assessment and training. The FBI contacted him to provide training at its academy in Quantico after he published an article in an academic journal on violence risk and assessment.

Law enforcement agencies are good at lots of things, but threat assessment isn’t always one of them, Moffatt says. That’s where his skills as a professional counselor can help fill in the “why” of a situation, he says.

Moffatt uses his counselor training to look at a specific situation’s “collection of evidence,” he says. For instance, how does the person tell his or her story? What indicators can be found in the language the person uses? What does his or her past behavior indicate? What coping skills does the person have?

“My job is to tell them [a company or law enforcement], ‘This is what I think; this is what you’re looking for,’” Moffatt says. “The question for us, in mental health, when someone’s sitting in our office is, ‘Is this person a risk?’ Sometimes the answer is yes. … How many coping skills does he [the client] have in his toolbox? If it’s a pretty empty toolbox, then I’m worried.”

For example, Moffatt was contacted by local law enforcement to evaluate the threat level of some letters a judge was receiving in the mail. Officials suspected the letters were being written by a man who had come through the judge’s courtroom for a minor infraction, he says.

Moffatt looked at the man’s behavior history (he had brandished a firearm in the past but never fired at anyone) and the language used in the letters. His counselor training helped him pick up clues — for example, symptoms of delusion and other things that would make a person unpredictable — to determine that the man was a “big talker,” but that the letters were most likely a way of “puffing out his chest” rather than an actual threat.

“I thought there was a very low possibility that he would shoot this judge. Years later, nothing has come of it,” Moffatt says.

Today, he works regularly with the Atlanta Police Department’s cold case squad and writes a regular column on children’s and family issues for The Citizen, a newspaper distributed in Fayette County, Georgia.

Moffatt says he is drawn to the sometimes gritty specialty of crime and violence assessment because he likes being part of the solution and helping to bring some closure to the victims of crimes.

“The world is not made up [solely] of bad guys and good guys,” he says. “If you go to any prison in the country, you will find a small percentage [of the inmates who] are horrible and need to stay locked up for the rest of their lives. The rest are human beings who have made a mistake. The hardest part about our job [as counselors] is to have compassion. We can take people, in any condition, and help them become more functional.”


Q+A: Gregory Moffatt


You encourage all counselors to learn more about risk assessment, whether through reading, professional development, trainings, etc. Why do you feel this particular topic is important for counselors to know?

Risk assessment is necessary in any clinical context. Violence happens in homes, schools, workplaces, on the bus, on the street and in the synagogue/cathedral. Assessing for violent behavior against others is just as important as assessing for suicide risk, [which is] something we do regularly. You don’t have to specialize in workplace violence or school violence for this to be part of your assessment toolbox.


Do law enforcement professionals often think of or turn to psychologists first when looking for help with mental health expertise? From your perspective, what can a professional counselor offer in this area that is different than other helping professions?

Actually, I don’t think most law enforcement people know the difference. Even when they do, they often have limited or no budgets for outside consultation. Professional counselors are cheaper than psychologists, typically. Counselors are just as competent to offer fitness for duty interventions/assessments, post-shooting intervention, violence intervention/anger management and other common needs in law enforcement as any psychologist — assuming, as always, that one is trained to deal with that population. This training is readily available to LPCs.


What suggestions would you give to counselors looking to help or make a connection with their local law enforcement or violence prevention agencies?

Law enforcement agencies are notoriously fraternal, and even agency to agency there is little cooperation. A given agency believes it is better than any other agency, and going outside law enforcement is seen as a negative. However, developing relationships and bringing skills to the table — especially if it is cost-effective — is the way in the door over time.


What are some of the main takeaways that you’ve gleaned from your work with law enforcement and risk assessment that you want professional counselors to know?

Behavioral/mental health issues are present in all corners of life. Finding a way to apply your interests in mental health in specific climates — e.g., schools, law enforcement, court — is what makes one’s career fascinating and rewarding. I look back on 30 years of work — opening doors, looking for opportunities and taking those opportunities — and I couldn’t be happier. I’ve helped hundreds of children, written hundreds of articles and numerous books, spoken to thousands of audiences and helped put many bad guys in jail — hence, making the world safer and people happier. Who could ask for more?




Read more about Gregory Moffat’s work and find a list of suggested resources on trauma, violence, parenting and other topics at his website, gregmoffatt.com




Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

Who influences today’s counselors?

Compiled by Bethany Bray March 3, 2016

WWYD_1Who are the major influences on today’s counseling professionals? What voices, both within and outside of the profession, are counselors listening to and intently following?

Recently, Counseling Today posed these questions to a random assortment of American Counseling Association members and a few select counseling leaders. The responses were as diverse as the association’s membership. From personal mentors and supervisors to eminent thinkers and authors, from human rights champions to neuroscientists and others on the cutting edge of research, today’s counselors are influenced by a wide variety of voices.


Editor’s note: This online exclusive article is an addendum to Counseling Today’s March cover story on influential thinkers. Many thanks to the numerous counselors across ACA who contributed to this project.





The counselor who has had the biggest impact on me is my clinical supervisor, Kim Kelley. She taught me the value of truly practicing self-care, rather than just giving lip service to it. She also helped me with patience and self-compassion. She is a shining example of what an ethical, humane practitioner is like.

Brad Reedy, a psychologist whom I have had the pleasure of knowing well, has also had a profound influence on the way I work with clients. He once said to me “the way you hold the client in your mind matters.” Having seen how well he holds clients in his mind, I have tried to emulate this.

James Hollis has written terrific books that compel a deeper examination of the human condition. He taught me that psychotherapy means “listening to the soul,” according to the Greek roots of those words.

Outside the profession, I have been most influenced by my parents, who together taught me the value of equality, generosity and the balance between a worldly life and a spiritual life. They believe that fortunate people have a responsibility to help those less fortunate, and I try to carry this idea from them in my daily life and work.

One of my biggest inspirations in life comes from the founder of Aikido, a man named Morihei Ueshiba. He was a very disciplined, thoughtful man and he developed this martial art to serve humanity. Aikido teaches self-control, patience, poise, relaxation, harmony and care for all beings. I have been profoundly influenced by his teachings and writings.

The author Hermann Hesse has deeply affected my thinking through his books, most notably Siddhartha and Steppenwolf. He writes with such heart, and he captures the beauty and struggle of humanity so well. — Peter Allen, program director for College Excel in Bend, Oregon






Aaron and Judith Beck’s version of cognitive behavioral therapy is by far the most influential to my practice. This model can be applied to a wide variety of problems and offers a strong framework for me, as a counselor, to conceptualize my clients’ problems. It also provides a multifaceted framework for client improvement. Behavioral techniques (e.g., relaxation) can be used to bring about rapid improvement in symptoms. This allows for more long-term cognitive change to occur as clients are able to gain relief from overwhelming emotional states. The model just makes sense to me.

Richard Ryan and Edward Deci are also currently large influences for me. They are in the world of psychology as a whole, but not heard about much in what we do as counselors. Their self-determination theory is important to my practice. This theory informs a great deal of my work with criminal justice clients, but I would encourage any counselor to investigate this approach to understanding human behavior and motivation. I believe self-determination theory can help us wrap our heads around client problems and, most importantly, solutions. — Jason E. Newsome, licensed professional counselor (LPC), approved licensed professional supervisor (ALPS) and president of Dayspring Counseling Center in Dunbar, West Virginia







I am a psychologist who has been a school teacher and principal. The people who influence me most and allow me to grow as a professional and as a person are my patients. Each of the people I meet with has a unique story and have chosen to include me in one of their chapters. I view that as a great honor to accompany them in those pages and listen to them as the writers. I listen to what motivates them and their style of writing. I listen for how they choose to express themselves and the pictures they paint with their words. I try to imagine their characters in their lives and how they have contributed to their growth. I help them recreate timelines, settings and plots. I listen and help them process what they believe to be the climax of their story and I guide them to use different points of view. They are the writers and I learn from their life stories and sometimes, if we are lucky, there are happy endings but I always know there is suspense and adventure in every one of my patient’ s stories. — Robyn Glickman, school and clinical psychologist in Michigan 




I rely on the works of brilliant psychiatrists who are neuroscientists such as Bruce Perry, Daniel Siegel and Bessel van der Kolk. Without understanding the brain, it is difficult to be effective as a counselor. The brain and mind impact each other which means at a minimum, the two are intertwined with thoughts, emotions, chemicals, genetic predisposition, previous experiences and misfiring neurons — which means that focusing on the psychology of the client alone is not enough. I am a licensed professional counselor in Macomb County, Michigan and most of my experience has been with children and adolescents; predominantly those with an array of anxiety and mood disorders and (who) often come with a history of abuse, neglect or trauma. In addition to an eclectic approach to counseling based on the popular theorists of our field, I use modalities such as neurofeedback and animal assisted therapy in my work. — Amy Johnson, LPC, unit marketing manager and director of the animal assisted therapy certificate at Oakland University School of Nursing, Rochester, Michigan





Paulo Freire has tremendously influenced my work as a counselor educator. Freire was a Brazilian educator who focused on the educational experiences of the most marginalized members of Brazilian society. His book Pedagogy of the Oppressed transformed how I view education and inspired my work with marginalized communities to foster critical consciousness. In my courses I avoid lecturing, reduce power differentials, encourage dialogue and questioning and promote critical consciousness in my students. Inspired by Freire, my research focuses on the oppression of marginalized groups; I study the negative impacts of racism and internalized racism. Freire’s teachings also inspired my research on strategies that promote critical consciousness and sociopolitical development in counseling students and K-16 (kindergarten through college) students. Freire’s notion of praxis (a circular marriage of theory and practice) is also a major influence. I am co-founder of a charter school that uses my work on sociopolitical development to foster the empowerment of marginalized students. — Carlos P. Hipolito-Delgado, associate professor and program leader in the counseling program at the University of Colorado Denver and chairman of the ACA Foundation





Within the counseling profession, my work has been most influenced by three specific theorists who have informed how I practice, how I believe mental health issues develop and how they are best resolved: Carl Rogers, William Glasser and Albert Ellis. I use one or a combination of the three approaches when treating clients. Rogers taught me how to treat clients that simply need a safe space to process and express. Glasser taught me how to help clients who make poor decisions. Finally, Ellis taught me how to resolve depression, anxiety and other mental health diagnoses and symptoms. Together, the three approaches can be used to treat almost any client that I would see.

Outside of the counseling field, the Dalai Lama has most influenced my views and my work. There are many things I appreciate about his views. Obviously, he has lived a life focused on helping others. He presents with very clear themes in his life: non-violence, appreciating the moment and spiritual harmony. He instilled in me the idea of living a principled life, one where we focus on ourselves as people and being harmonious with nature, instead of being focused on the past, the present or material gains. He has also modeled activism, a key facet of being human and being a counselor who advocates for my clients. — Patrick Powell, licensed mental health counselor (LMHC) in Florida, Licensed Professional Counselor-Mental Health Service Provider (LPC-MHSP) in Tennessee and assistant professor and director of the Counselor Education and Supervision Program in the College of Counseling, Psychology and Social Sciences at Argosy University in Sarasota, Florida as well as president of the Florida Association of Counselor Education and Supervision





Oprah Winfrey is the preeminent voice that influences my counseling practice with athletes. Her personal and professional life stories provide both an example and game plan for how to become your best in your own life. The athletes that I encounter at all levels are expected to perform at their physical peak before they have fully completed their development as a person. I view my role in performance enhancement as helping athletes develop other strengths to help improve their sports performance. Oprah has created a world through her interaction with other leaders where being who you are, right where you are, is okay. But she stresses to start the work of personal growth from there! — Vonetta Kalieta, LPC, instructor in the Graduate Department of Psychological Counseling at Monmouth University in West Long Branch, New Jersey and practitioner at Learned Excellence for Athletes in Tinton Fall, New Jersey





The caregivers and children (that I work with) have shown me the immense potential for global change held within attachment relationships. They have taught me to trust the process, especially the parallel process. In genuine, therapeutic relationships support of the primary caregiver (and) the caregiver’s attachment relationship with that child can heal and grow. The growth often spills over into positive behaviors, self-esteem and healthier relationships with others. It is remarkable. — Anna Van Wyck, LPC and infant and family specialist in Mears, Michigan





I, like many counselors, use different approaches to my counseling. I work with college students, and find that Cognitive Behavioral Therapy (CBT), positive psychology and the solution-focused [approach] work well. For traditional aged college students this is often the age when depression and anxiety are first showing up, so I feel it’s helpful to use methods that will give them tools to learn how to cope and help themselves. CBT is also one of the most widely studied therapies for depression and anxiety and it also works well with various cultures.

As a college counselor I also do career counseling. I use some of the work by Mark Savickas, which is more narrative in approach. For students, it is often helpful to work with them in career counseling to help them connect with prior life experiences and interests to help assist in the career decision-making process. — Amy Lenhart, LPC, a counselor at Collin College in Frisco, Texas and president of the American College Counseling Association, a division of ACA





Rarely does a client come to us without some type of crisis in process. As counselors, we thrive on helping people make meaning of the challenging events that may overtake their lives or rewrite dysfunctional beliefs that may improve their life stories. Yet, these efforts take a remarkable toll if the “givers” do not replenish their minds, bodies and souls. Robert Wicks, psychologist, prolific author, speaker and sage has spent his career exploring how resilience is nurtured and sustained to promote growth post-trauma. Of particular note is his concentration on how caregivers can help themselves by finding crumbs of alone time, conducting daily debriefings, jettisoning false personal beliefs and practicing mindfulness. My personal favorite is his theme of “being faithful in the moment” with clients, family, friends and self. Crises will come, but it is how we handle them personally and with our clients that will be remembered. — Tina Buck, a licensed graduate professional counselor at Carroll County Youth Service Bureau in Westminster, Maryland





Resilience theory has been influential to my counseling practice, including the ideas of Steven M. Southwick, George A. Bonanno, Ann S. Masten, Catherine Panter-Brick and Rachel Yehuda (co-authors of the 2014 journal article Resilience definitions, theory, and challenges: interdisciplinary perspectives). As I work with children and adults who experienced trauma, a key factor is guiding the development of resilience. Masten noted “positive assets” in the individual provide strong potential for resilience, and recognized spirituality and religious beliefs as important. With great amount of effort to counsel and help those who are experiencing negative effects following a trauma event, Bonanno suggests the need to focus on “what goes right in people who negotiate potentially traumatic events with equanimity.” Resilience theory changes perspectives noting, “the experience of trauma does not only yield pathology.” In counseling, I want to provide clients with support and clinical perspective integrated with elements that spawn and develop resilience.

Outside of the counseling profession, the greatest influence on my work comes from strong religious leaders. Speakers such as Ravi Zacharias (Ravi Zacharias International Ministries), John Ortberg (Menlo Park Presbyterian Church) and Josh McDowell (Josh McDowell Ministry) emphasize the importance of maintaining faith, hope and prayerfulness. They encourage compassion and forgiveness as important to healing and healthy living, which are attributes supported by research (Baskin and Enright, 2004). Many individuals who seek counseling note that faith-based practices are desirable and soothing. Faith-based characteristics reflect counseling ethical practice such as genuine caring, non-judgmental acceptance and kindness. Ideas from a faith-based perspective strengthen counseling focus, empathy and compassion as well as serve to provide a means of self-care for the counselor and healing properties to clients. For these reasons, gleaning from religious leaders inspires counseling work that is wholesome, passionate, fully engaging, client centered and self-supportive.

Susan Luck, a licensed clinical social worker (LCSW) in New York and Virginia and instructor of graduate counseling and human services courses at Liberty University Online






There are many influential individuals within the counseling realm that have influenced my work. One such individual is Brené Brown (research professor at the University of Houston Graduate College of Social Work) who has helped shape me into a better counselor but as an individual as well. Her research on imperfection, shame, courage, living whole-heartedly, self-compassion and living authentically have started to become the bedrock of my approach. These principles, when applied with Dialectical and Cognitive Behavioral Therapies, have made a strong impact on my clients. These principles are important because if we can pull out our thoughts, behaviors, secrets and whatever we don’t talk about, the fear of shame and guilt can be put out there with people that we trust and know that trust wouldn’t be violated. Brown explores the importance of talking about these things in our lives, which allows us to be vulnerable and really connect with each other on a whole-heartedness level. — Noor Pinna, LMHC and owner of a private practice in Fishkill, New York





Over the 50+ years of my connection to counseling, there have been significant changes. In the beginning, we studied core philosophies of theorists such as Carl Rogers and Albert Ellis. There was a tendency, even then, to skip study of the core philosophies and jump to use of the responses (e.g., techniques) emerging from those theorists — a flawed practice since attempting to emulate another without being that person is inevitably faulty.

The contemporary influence of Bill Gates and Steve Jobs has made that “practice-sans-theory” approach become even more extensive. I can even download an app that will send a daily note of encouragement to a client — and I don’t even have to know what it says. I’ll be interested to listen to ACA conference discussions to see if practice emerges from philosophy. I suppose I could just Google my question — or ask Cortana. — Brooke B. Collison, professor emeritus of counselor education at Oregon State University and ACA past president (1987-1988)





I have been drawn to the social equality philosophy and individual psychology of Alfred Adler as represented principally in the works of Rudolph Dreikurs, whom I had the pleasure of knowing for a brief time before his death. Child and classroom guidance, parent education and the influence of one’s early life experiences as revealed in early memories first got my attention as “common sense” and teachable.

As a practitioner, Dreikurs’ empathy was based upon insight into the human condition. He had little time for contributing to anyone staying in a state of emotional upheaval. Both Dreikurs and Adler were strategists who gently invited clients to enter into a dialogue. Then they used their unique skills to uncover and challenge mistakes in one’s private logic and guide clients to new approaches in their life tasks at work, in their families and friendships, identity and spirituality. Their practical methods based upon a sound philosophy won me over. — Thomas Sweeney, professor emeritus of counselor education at Ohio University, executive director emeritus of Chi Sigma Iota International and ACA past president (1980-1981) who lives in Lexington, North Carolina





Richard James has worked for more than 30 years developing training, prevention and intervention programs for law enforcement, military and community agencies to address the timely issue involving the intersection of mental illness with law enforcement/corrections/military veterans in crisis situations. I’ve had the honor of studying under Richard James as a student and currently work as a junior faculty under his mentorship co-leading the Crisis Research Team (at the University of Memphis) in engaged research projects. His thorough text on crisis intervention strategies outlines the (crisis intervention) training he pioneered 30 years ago to train law enforcement to identify and de-escalate people with mental illness in the field, which is used in thousands of jurisdictions on three continents. Although he is at the end of his career, he exhibits incredible passion for mentoring junior faculty and masters and doctoral students in engaged research towards helping discover viable solutions for improving the treatment of mentally ill offenders.

As a play therapist and someone who works with offenders and addictions, I am also influenced by several clinicians/researchers who together help me practice neurobiologically-informed counseling. Paul Wachtel articulates relational psychoanalysis as it is practiced in contemporary settings. He describes a therapeutic approach that is flexible, technically eclectic (including behavioral therapy) and connects with the emerging evidence of interpersonal neurobiology that helps me conceptualize client-therapist dynamics. Bruce Perry’s work in interpersonal neurobiology as it relates to trauma and the concept of neurosequential interventions has influenced my continuous assessment and choice of intervention strategies with addiction and offender clients from a developmental perspective. I have found this to be most effective in engaging challenging clients to really work in treatment. Finally, the creators of Theraplay, Phylilis Booth and Ann Jernberg, provide a framework for an object-relations/attachment approach to working with interpersonal trauma that has helped me improve outcomes with challenging populations. — Leigh Falls Holman, licensed professional counselor-mental health service provider (LPC-MHSP), registered play therapy supervisor (RPTS), clinical mental health counselor (CMHC, assistant professor in the Counseling, Educational Psychology and Research program at the University of Memphis, associate editor of the Journal of Mental Health Counseling and president of the International Association of Addictions and Offender Counselors (IAAOC), an ACA division





For me, the most influential figure for establishing and developing a positive counseling relationship by the use of empathy and unconditional positive regard is Carl Rogers, augmented by the work of Gerald Gladstein, a pioneer of non-verbal communication and Howard Kirschenbaum, who tirelessly advanced knowledge of Carl Rogers as a person, philosopher, practitioner and giant in the counseling field. He kept Roger’s work fresh and more relevant to newer generations of counselors. The most influential person for providing assessment tools and strategies for helping clients know who they are, and how vocational personality informs decisions related to choosing a college major or program of study and occupation is John Holland, as augmented and advanced by Janet Lenz and Robert Reardon (co-authors of Handbook for using the Self-Directed Search: Integrating RIASEC and CIP theories in practice). Reardon and Lenz integrated these two theories of vocational choice with the self-directed search, and nestled it into college career and counseling centers where it can maximize Holland’s influence. — Peter A. Manzi, national certified career counselor (NCCC) and master career counselor (MCC) who lives in Rochester, New York. He is also contributing faculty in the School of Counseling, College of Social and Behavioral Sciences at Walden University





Wow. This is a tough question! I would have to say (my influence) is Jon Carlson. There are two specific reasons for this. First, as a clinician—specifically an Adlerian, Jon’s scholarship in the work of Alfred Adler and his approach is seminal. He has been an ambassador of Adlerian therapy to the counseling field, and has influenced the wider recognition and acceptance of Adler’s ideas and practice in schools and in mental health settings. As a counselor educator, Jon Carlson has been influential to me through his vast library of video recordings that he has produced with the acknowledged masters in the field for over 20 years. These videos have a simple, yet overwhelmingly effective formula that I feel is invaluable to educators and trainees: Use real clients in live settings, and watch the entire interaction without interruption. And while it might be easier to use actors and more efficient to use scripts, I have found no better tool to help illustrate the processes of effective counseling. Truly, this is his gift to the field, and we are the beneficiaries.

Also, I would have to say I am influenced by the work of John Gottman (and his wife, Julie Schwartz Gottman). As one of the foremost researchers in couples and couples counseling, John Gottman’s approach has utilized observational methods to painstakingly study the relationships of well-functioning and poorly functioning couples. He has observed the key sequences in ordinary, everyday interactions that have allowed for old myths to be shattered. In addition, Gottman employs cutting-edge mathematical modeling to derive some of the essential dynamics of the couple relationship that I have modified in my own research on the therapeutic relationship. I am using his affective coding schemes and mathematical modeling equations to look at novice and master clinicians to decode the key sequences in the therapeutic relationship, and hope to uncover the key elements to successful counseling endeavors. In addition, as clinicians, the Gottmans have put their research efforts into a training program that is impacting thousands of therapists and even more couples to work through complex issues and lead better lives. — Paul R. Peluso, LMHC, LMFT, professor and chairman of the Department of Counselor Education at Florida Atlantic University in Boca Raton and president of the International Association of Marriage and Family Counselors (IAMFC), an ACA division





The late, great Viktor Frankl Holocaust survivor, psychiatrist, neurologist and author of the prolific Man’s Search for Meaning is my go-to source for inspiration and guidance when it comes to troubleshooting irrational thinking and behaviors. Frankl believed that dysfunction is driven by the lack of an individual to perceive the meaning and purpose they have in life. Rather than enhancing the self through an internal locus of control, people focus more on their external locus of control to make themselves feel valued. In the 1960’s, Frankl stated that the U.S. population was far more materialistic than the German population. This can be the result of the onslaught of commercialism that emerged in the mid 20th century that conditioned people to move their beliefs to wanting material things rather than procuring items they actually needed. It is not things that nurture a true sense of belonging, but the procurement of non-material cognitions. — Vanessa L. Dahn, LPC and adjunct professor of sociology and psychology at Colorado State University-Pueblo, Pikes Peak Community College and Southern New Hampshire University as well as executive director of Safe Landing Group Center, a facility for at-risk youth in Calhan, Colorado






Like many counselors, I apply an eclectic approach to therapy and it seems that regardless of the presenting problems, way in which information is gathered, treatment goals are established and interventions are implemented, the theories that tend to drive these processes for me almost always come back to Fritz Perls, Carl Rogers and Albert Ellis. The importance of self-awareness emphasized by Perls, as well as the humanistic perspective on self-actualization influenced by Rogers and Ellis’s practice of cognitive restructuring in an effort to challenge self-defeating irrational thoughts are all foundational concepts to my practice that weave their way in and out of sessions throughout the entire therapeutic process. — Alyson Carr, LMHC, qualified supervisor and doctoral candidate at the University of South Florida in Tampa





Because I specialize in neurological cases, I like the work of Daniel Siegel. He gives beneficial information about counseling and the brain. I like psychiatrist John Ratey for bringing our attention to exercise and mental health. Norman Doidge and Jeffrey Schwartz are impressive with their work on neuroplasticity, which explains how change is attained biologically through therapy. I also like the work of M. Scott Peck, who was one of the most brilliant minds in psychiatry and psychotherapy in the 20th century, in my mind. Every counseling professional and student should read (Peck’s book) The Road Less Traveled. Cardiologist Herbert Benson discovered the relaxation response in the 1970’s and really changed the way medicine views the person. Instead of viewing the human being as dichotomous, we found out the human being is really integrated system. — Kevin Wreghitt, a mental health clinician counseling people with disabilities in day habilitation and college settings in Massachusetts






From within the profession two men have influenced my thinking greatly, and I cannot say one more than another because both have been creative visionaries: Gilbert Wrenn and David Tiedeman. Each was each was ahead of his time in foreseeing the usefulness of the computer and the advances technology would bring to the counseling professional. Yet both were holists, humanists and poets. I was fortunate enough to meet each of them before I was president of ACA and both communicated with me in poetry and prose throughout my presidency, sending encouragement and inspiration.

Two women also have influenced me professionally. The first, Katherine “Kitty” Cole, and I met at a conference. She was president of the National Career Development Association (NCDA) at the time. I was barely involved. She said that she thought I had talent. Whether I did or not is moot. She put me on a committee. I was hooked. Thelma Daily (ACA president 1975-1976) is the other woman. Never had I met someone so encouraging. Model par excellence, as she did for so many, she mentored me. — Lee Richmond, professor of education at Loyola University in Baltimore and ACA past president (1992-1993)




My clinical work is informed by the legendary Irvin Yalom. Author to a plethora of fiction and nonfiction writing, Yalom has been instrumental in promoting therapeutic transparency and embracing the humanity of self and relationship. He suggests that when we dare to confront (what he calls) the four “givens” of existence (inevitable death, aloneness, free will and the need for meaning construction), it is possible to experience personal growth and change. All of Yalom’s work centers around the authenticity of relationship and to this, I am indebted.

Last year when my article “What Would Yalom Do” (a tribute to his work When Nietzsche Wept) was published, Irvin Yalom emailed me his gratitude in observing his work. He is not a man who needs my endorsement. Yet, he took the time to thank me. This is a man who exceeds his scholar, he is an artist. — Cheryl Fisher, a Licensed Clinical Professional Counselor (LCPC) in private practice in Annapolis, Maryland and visiting full-time faculty member in the Pastoral Counseling Program for Loyola University Maryland




We invite you, in turn, to consider who influences your work as a counselor. The exercise may spur some self-reflection on what methods and philosophies you place value on and how you have learned and evolved over the course of your career. We encourage you to share your responses in the comments section below.





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


Letters to the editor: ct@counseling.org


Handle with care: Addressing child trauma in West Virginia

By Bethany Bray May 5, 2015

“Their normal is chaos, and we have to bring calm.”

For public school students in West Virginia, the calm therapist Felicia Bush is referring to comes in the form of an innovative, multidisciplinary program that aims to identify and treat trauma in real time.

Bush, a provisionally licensed social worker with a master’s degree in counseling, provides trauma-focused therapy for youth in the public schools through the Defending Childhood Initiative (DCI). The program brings together law enforcement, public school staff and mental health professionals to create a HandleWithCaresafety net for youngsters, bridging the gap between what happens at home and the hours they spend at school.

For example, a child might witness police responding to a domestic violence incident that occurs in the home in the wee hours of the morning. Through DCI, police officers are trained to note whether a child was present during such incidents. Officers then find out what school the child attends and file a “handle with care” notice with the school. The one-page form doesn’t provide details about what happened but simply lets the school know that the student may need extra attention.

“The child sometimes discloses what happened but not always,” Bush says. “You don’t have to know what happened. You just have to know that something happened that potentially can affect the child’s ability to learn.”

In other cases, a parent or caregiver might alert the school that something is going on at home, such as a parent’s impending military deployment or the death of an extended family member.

After being alerted, DCI’s network clicks into place to provide whatever extra care the child may need at school — from a space to shower, nap and change clothes to a chance to retake a test to recurring sessions with a trauma-focused therapist.

Law enforcement personnel and entire school staffs — from principals to the cooks in the cafeteria — complete DCI training to help them identify and be sensitive to child trauma. The initiative is designed to stem both the short-term and long-term effects of trauma, especially its impact on children’s ability to learn.

“Trauma is a public health issue, not just a counseling issue,” says Carol Smith, a licensed professional counselor (LPC) and member of the DCI advisory board in West Virginia. “[Addressing this] is a huge paradigm shift, and it’s going to take all of us.” That includes medical and mental health professionals, educators, law enforcement personnel, religious leaders and others in the community, she says.


Getting started

The DCI in West Virginia is a localized version of a program first introduced by U.S. Attorney General Eric Holder. He launched DCI in 2010, prompted by the plentiful research showing that trauma affects a child’s ability to learn and is associated with long-term physical and mental harm.

In West Virginia, U.S. Attorney Booth Goodwin has overseen the launch of a DCI program tailored to local needs, including creation of the “handle with care” form used by law enforcement.

A group from the Child Witness to Violence Project, a successful multidisciplinary trauma-focused program in Brockton, Massachusetts, came to West Virginia in 2011 to train DCI participants before the program launched in pilot schools, according to Tracy Chapman, the victim witness coordinator in the U.S. Attorney’s Office for the Southern District of West Virginia.

“We looked at what works, and we looked at the needs of West Virginia — the needs that are impacting our children, our classrooms,” she says.

The first pilot schools in West Virginia adopted the program in 2013. In less than two years, law enforcement personnel have recorded 414 incidents involving 768 children through DCI, according to Charleston Police Lt. Chad Napier, a coordinator for the program.

Now, after its success in five different pilot schools at the elementary, middle and high schools levels, the stage is being set to roll the DCI program out statewide.

This spring, it was announced that the DCI program will now be headquartered in the newly created West Virginia Center for Children’s Justice, located at a state police facility in Dunbar. This change will allow DCI to be more easily implemented statewide while adhering to a consistent model, Chapman says.

“We can no longer work in our silos focused on one piece of a child’s life puzzle. We must work together to make systemic improvements that can truly change the trajectory of a child’s path,” Goodwin said at the center’s unveiling. “… This [Center for Children’s Justice] will improve communication and collaboration between law enforcement, prosecutors, schools, advocates and mental health providers, and help connect families, schools and communities to mental health services.”

Goodwin has been the driving force between DCI in West Virginia, making it a personal priority, Chapman says. “As a federal prosecutor, we can’t arrest our way out of crime and the types of problems that are affecting our communities,” she says. “We have to provide the resources to children and to communities and to schools to actually change and break the cycle. We have to intervene early, and we have to intervene effectively with kids to help keep them on the right track. That’s his [Goodman’s] message.”


Creating a safety net

Through DCI, school staffs work to provide as much specialized care as possible for trauma-affected children, such as partnering them with a mentor or ensuring that they can make up missed homework. The school counselor plays an integral role in these efforts, from readying a schoolwide traumatic crisis response plan to identifying children and families who could benefit from extra mental health support, says Smith, a member of the American Counseling Association and president of the West Virginia Counseling Association.

When children affected by trauma need extra help beyond what the school can provide, they are referred to mental health practitioners who provide in-school therapy as part of DCI. All of these practitioners are specially trained to treat trauma. One of DCI’s pilot schools, an elementary school in Charleston, has established a permanent mental health clinic in the school.

“[DCI] gives services to the child immediately upon the experience of a potentially traumatic event. If it’s needed, the service is there, and there’s no stigma to it,” says Bush, executive director of Harmony Mental Health, a nonprofit mental health and social services agency based in Parkersburg.

Prior to the launch of DCI, Bush says, school staff members had to guess when something had happened in a child’s life outside of school, clued in by sudden behavior changes or when Child Protective Services personnel came to the school — often weeks later — to ask the child questions. Now the initiative is allowing professionals to help students deal with trauma in its immediate aftermath.

Professionals involved in DCI agree that the program is helping to reach students who might have previously fallen through the cracks and not been identified as needing help. “A lot of these kids were never on anyone’s radar unless they were a direct victim,” Chapman says.


A culture of safety

In addition to providing extra help for individual children, the DCI program trains educators to introduce schoolwide initiatives that focus on mental health.

In one example, the school principal and other staff members greet students coming off the bus each morning. The students are asked to give a thumbs up or thumbs down, depending on how they are feeling that day. The principal uses this to gauge the school population’s overall climate for the day and tailors the school day accordingly. On “thumbs down” days, this could include having a therapy dog visit the school, postponing testing or introducing extra small group counseling sessions with a school counselor.

A similar initiative is introduced for classrooms. Upon arriving, students are asked to take a marble and place it in a bowl. They select a green marble if they are feeling OK and a red marble if they are feeling bad. The teacher can gauge the classroom’s needs by checking the bowl, adding extra wellness initiatives to the day such as breathing exercises or playing soothing music in the classroom (see sidebar, below).

The program also requires a provider of trauma-focused cognitive behavior therapy to be available at each school, Chapman says.

Individual children who are referred to mental health practitioners through DCI are given an initial screening to see whether they need general counseling or trauma-focused counseling, Bush says. If the case does involve trauma, the therapist will go over a treatment plan with the child’s parent or caretaker.

In addition to trauma-focused cognitive behavior therapy, the mental health practitioners provide lots of psychoeducation, Bush explains. DCI therapists work to help the children understand what trauma is and guide them in learning coping mechanisms, including the management of behavior, anger and emotions.

“Some of [these children] have no ability to identify or control their emotions,” says Bush, who has worked with victims of domestic violence and trauma for more than a decade. “The goal is to help them identify the trauma they’ve experienced, put it into a narrative and begin to express it so it doesn’t affect them for their whole lives.”

Because the therapy is conducted in the schools, mental health practitioners are able to collaborate with school staff, check in often with the children’s teachers and see the students “in context,” Bush says. The mental health practitioners often visit a child’s classroom, the lunchroom or a gym class just to observe the child in a group setting. “We do a lot of listening,” Bush says.

By being so ingrained in the schools, the therapists are also able to schedule therapy around field trips and other events the child would not want to miss, Bush says. Teachers have been very willing to work with Bush and her therapist colleagues, she says, even participating in department and individualized education plan (IEP) meetings when asked.

One of the most helpful aspects of the DCI program is that the children “realize they’re important to us [the adults], to the school and to all the people who have put in extra effort to make this available for them,” Bush says.


It takes a village

The DCI program brings together professions that were not always good about communicating with one another, Chapman notes. “Unfortunately, for far too long we’ve all worked in our individual silos. Children do not live in silos. They live in all of our worlds,” Chapman says. “… For far too long we haven’t communicated and collaborated and broken out of our silos to make sure that we’re comprehensively addressing the needs of the child. For far too long these kids have fallen through the cracks.”

Chapman and Bush both use the metaphor of putting pieces of a puzzle together to describe the program’s multidisciplinary approach.

“We all have a little piece of the puzzle, a little piece of a child’s life,” says Bush, adding that anytime those puzzle pieces are connected, it benefits the child. “We’re blurring the lines for the benefit of the child. Not the lines of confidentiality or procedure, but making the community safer by providing a safety net for children so they’re not the next generation of perpetrators or the next generation of adult victims.”

Treating the effects of trauma in young children “is the only place we can truly change the cycle of violence in our community,” she says.

DCI stakeholders — including law enforcement personnel, public school representatives, mental health providers and community partners such as social service agencies — meet often to review and evaluate the work being done.

In some ways, the program’s training has also ushered in a cultural shift, Chapman says, in part by introducing a level of care and follow-up that didn’t often exist previously in the state’s law enforcement. New protocols guide police to avoid making arrests or interviewing witnesses in the

Blackwater Falls State Park, West Virginia

Blackwater Falls State Park, West Virginia

presence of children whenever possible and to make regular, noncrisis visits to local schools.

“There’s a whole new culture and mindset in the police department that they need to recognize when kids are present [during an incident] and the potential impact that could have on the child,” Chapman says.


In your neighborhood

DCI was launched in some of the neediest schools in West Virginia. At the program’s first pilot school, an elementary school in Charleston, 93 percent of the students are from low-income families. But those involved in the initiative agree that DCI’s multidisciplinary approach is needed everywhere as well.

All communities have children and households that are affected by trauma, Chapman notes. “We all have to think differently. … If we continue to do the same things we’ve always been doing, we’ll continue to get the same results. That goes for schools, mental health [practitioners] and law enforcement,” Chapman says. “Counselors play a vital role in this process as well. … I would encourage mental health providers to think outside of the box [and] understand the limitations that some families have with coming to their offices [outside of the school day].”

“People don’t exist in a vacuum of 50 minutes” — the length of a typical in-office counseling session, agrees Bush. “You want to send them out into as much support as you can possibly garner on their behalf. If you want [clients] to be successful, it’s a no-brainer. Make yourself familiar with all the [support] systems that are available.”

The collaborative work being done in programs such as DCI involves going the extra mile, but it’s well worth it, Bush says. “Step out of your comfort zone and you will have a richness of experience that you can’t imagine,” she says, her voice breaking with emotion. “Open up your world to experiences, people and situations that you wouldn’t normally experience. It’s just such a growth experience for everyone.”

DCI also models what adults regularly try to teach children: to be cooperative. “[Students] see adults working together not in a negative way, but in a healing way,” Bush says.

Both Chapman and Bush stress that communities interested in DCI should adopt the program as a whole. It doesn’t do any good to have law enforcement record and refer children involved in traumatic incidents unless a trauma-sensitive network is set up in the community’s schools, Chapman asserts.

“It takes all these components working together to get this initiative to succeed,” Bush agrees. “It’s important that [communities] don’t piecemeal it.”


Meeting a need

Through her involvement in DCI, Smith has decided to devote the remainder of her career to focusing on trauma. At Marshall University, where she is an associate professor of counseling, Smith is involved in the launch of a graduate certificate program in violence, loss and trauma counseling. In addition, several Marshall University counseling interns have been involved in DCI under Bush, Smith says.

“When your eyes are opened to trauma, you realize it’s everywhere. Everyone who walks through your door has it, and if you don’t handle it correctly, you can restigmatize or cause harm,” Smith says. “Counselors can become change agents in the community. … The field is waking up and becoming savvy to the issues that are swirling around us. Yes, it’s exhausting, but it’s worth it.”




Learn more about DCI in West Virginia: handlewithcarewv.org


Much of DCI’s schoolwide trauma training is adapted from the book Helping Traumatized Children Learn, a publication of the Massachusetts-based Trauma and Learning Policy Initiative. Find out more, and download the book for free, at traumasensitiveschools.org.





Classroom initiatives for “thumbs down” days

What should happen on days when the majority of students indicate that they’re not OK? The possibilities are limitless, says Carol Smith, a licensed professional counselor, member of West Virginia’s Defending Childhood Initiative advisory board and president of the West Virginia Counseling Association.

Examples of activities to calm and refocus students include:

  • Doodle-quilts: Each child is asked to take out a 4-by-4-inch piece of paper (already cut and available for such a time as this) and to spend five minutes quietly doodling on it in whatever colors the child chooses. Students then pass the pieces of paper to the front of the room. The teacher tapes the pieces together and posts the “quilt” of doodles on a bulletin board, observing that the doodles show the students’ “processing” of whatever caused the heated (unhappy/stressed) temperature.
  • Round robins: Children sit or stand in a circle, facing each other. With the process explained and structured by the teacher, each child, in order, identifies one thing that is on his or her mind. The teacher summarizes, validates, encourages and then redirects the children to the work at hand.
  • Stand up and stretch: The teacher validates the students’ collective temperature and provides structure: “We are going to breathe a few breaths and do a few stretches to process our feelings, and then we’ll get to today’s lesson.” The teacher takes students through a couple of deep breaths and a short series of stretches to allow students to “reboot.” The verbal validation, structuring and limited activity work to restore equilibrium and allow students to get back to business.
  • An agreed-to, brief regrounding ritual that has been previously co-constructed by the teacher with the children, typically at the beginning of the school year.

Source: Carol Smith, associate professor of counseling, Marshall University




Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org


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