Tag Archives: risk

Voice of Experience: The danger of misinterpreting risk

By Gregory K. Moffatt September 28, 2023

Wooden cubes in the form of a speedometer showing the risk assessment. Hand holding pencil is pointing toward medium to high risk.

Fida Olga/Shutterstock.com

Last month I addressed the topic of dangerousness in mental health. I noted that most people with mental illness are not dangerous and that, among those who are, they are more likely to be a risk to themselves than to others. In this month’s column, I focus on who isn’t dangerous and how our fears and stigmas can sometimes cause us to mistakenly perceive someone with a mental health disorder as a threat.

Some years ago, an attorney in south Georgia called me and asked me to consider testifying in a murder case in which the attorney was counsel for the accused. The defendant had an IQ of just under 70 and he had allegedly killed his mother. The attorney wanted me to testify that the defendant’s IQ was responsible for his violent behavior.

I had to decline that request, of course. While it is true that intellectual challenges may limit one’s problem-solving skills, there isn’t any evidence that indicates intellectual limitations “cause” one to be violent.

Violence in psychiatric hospitals

In psychiatric hospitals, patients can be aggressive with each other and with staff members, but there are reasons for this other than the psychiatric disorders themselves. Although mood disorders, anxiety disorders and even personality disorders (with the exception of those I addressed last month) may be contributing factors in aggressive acts, rarely do they directly cause violent behavior

First of all, in hospitals, people with serious dysfunctions are concentrated together in a confined space. Therefore spats, disagreements and fighting are not unlikely in such environments.

Second, these patients may be withdrawing from substances, managing complicated relationship issues and managing financial burdens all in the context of their mental health issues. These added stressors on top of their diagnoses can increase the probability of aggression. It is not caused by the diagnosis itself.

Finally, some of the most aggressive individuals, as I addressed in last month’s column, can be found in hospitals, so it isn’t surprising that we see aggression in hospital settings.

Misleading data

Early research on violence and mental health was nearly all done within inpatient settings. John Monahan’s 1981 monograph was a classic example of this type of research. While it was an exceptional work, the research presented a skewed perspective on mental health in general. The findings of those early studies couldn’t reasonably be generalized to the population at large.

I aimed to address this gap in the literature by exploring violence risk assessment in the general population in my first academic article, which was published in 1991.

What we now know is that, excluding hospital practice, most of us in the mental health industry will never be assaulted by our clients, and most of our clients will never harm or attempt to harm anyone else. A widely cited study published in the American Psychological Association in 2008 indicates that 35% to 40% of psychologists are at “risk of being assaulted” by their patients. “At risk,” yes, but most of them aren’t.

In a 2011 study, the National Institutes of Health (NIH) noted that 14% of patients admitted to a psychiatric hospital had been aggressive toward other individuals in the month prior to admission. Yet again, those who are hospitalized represent a narrow segment of the overall population.

In another NIH study in 2019, researchers found that over half of the 470 clinicians in their study had been subjected to threats, verbal attacks or physical violence at some point in their career. While this is an astonishingly high percentage, we see again that “threats” are mixed in with the data of actual aggressive clients. The participants in the study reported confrontations by clients outside the office, harassing phone calls and other verbally aggressive behaviors that fell short of actual physical contact. Feeling threatened and actually being assaulted are not synonymous.

Recognizing real vs. perceived threat

I once consulted with a company that routinely hired housekeeping staff from an agency that worked with individuals on the autism spectrum as well as individuals with development disabilities. One adult male autistic worker had been working for the company for more than three years without incident even though he was on the severe end of the autism spectrum.

As we know, people with autism often don’t handle changes well. Any disruption in their routine can cause them to be agitated. In this particular incident, this worker had gone to the maintenance area as he had done hundreds of times before, but for some reason the closet where his equipment was kept was locked.

The worker became extremely agitated and was ranting in the hallway to himself, pacing back and forth. Another employee of the agency felt threatened by him, and he was eventually fired. It was a tragic end. The employee’s fear of the agitated worker is understandable, but he was no threat to the employee nor anyone else in the office.

Recognizing who is actually a threat and who is not is a critical part of our work in mental health. Individuals who are not a threat, but inaccurately deemed to be so, can lose their jobs, custody of their children and potentially their freedom, among other things. There are also dire consequences in cases where people are a threat but inaccurately deemed not to be so, including the potential loss of life.

My experience has shown me that most therapists are not well trained in distinguishing between the two. In a workshop some years ago where I presented a seminar on violence risk assessment and self-harm assessment, I asked the roomful of 100 or so clinicians how many of them worked with suicidal clients. Every hand went up. When I asked how many of them felt well trained in assessing risk, only two or three raised their hands. None of them had any significant training in their graduate programs on risk assessment.

That leaves the responsibility for learning risk assessment to the clinician. We must stay current on the research on risk assessment, and we must interpret the data cautiously.

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

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

The need for standardization in suicide risk assessment

By Gregory K. Moffatt April 14, 2020

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

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

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

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

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

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

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

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

Looking back

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

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

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

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

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

Risk assessment tools

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

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

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

How do we know our assessments are effective?

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

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

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

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

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

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

What we risk

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

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

A standard approach

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

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

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

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

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

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

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

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

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

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

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

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

Assessment of Abigail

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

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

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

Conclusions

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

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

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

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Gregory K. Moffatt is a veteran licensed professional counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University in Georgia. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. He also writes the monthly Voice of Experience column for CT Online. Contact him at Greg.Moffatt@point.edu.

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

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

Fraudster targets counselor’s innate empathy

By Bethany Bray October 20, 2016

Picture this scenario: You’re a counselor in private practice and a potential client contacts you via the email address listed on your practice website. The emailer expresses interest in attending marriage counseling with his wife, then goes into detail about the specifics of his situation and the struggles he and his wife are facing.

He requests to set up a series of appointments over four weeks while he and his wife are in town visiting relatives. After a series of emails back and forth, you discuss pricing and schedule appointments for the couple at your practice.

No cause for concern or reason to put up your guard, right? Not so, asserts a licensed professional counselor (LPC) and American Counseling Association member in Colorado who says she fell victim to a scam that followed that exact series of events, resulting in her losing several thousand dollars.

She agreed to share her story publicly with CT Online (on the condition that her name be withheld) because she wants to make other counselors aware of a scheme that preys particularly on their desire to help others.

“Even though we [counselors] are helpers, we are not immune to fraud,” the LPC says. “It wasn’t even on my radar to be thinking someone might try this. … I would want other counselors to know that people could be wanting to scam us at any given point in time.”

The fraud occurred when the emailer sent the counselor a cashier’s check in advance to pay for his couples counseling sessions. He contacted her soon after and explained – in multiple convincing, well-written emails – that there had been a mix-up and that the cashier’s check had mistakenly been made out for more than he owed her. He asked the counselor to send back the extra funds, and she agreed. After she wired the extra money back to the “client,” her bank returned the cashier’s check as uncollectable.

Unbeknownst to the counselor, banks often will make funds available before they are fully clear, which can sometimes take months.

“I didn’t want to hold on to money that wasn’t rightfully mine. I was trying to be the professional and do the right thing for these people,” she says. “When I found out I had been scammed, I went into the worst panic attack I have ever had. I couldn’t even hold my phone. I couldn’t talk. I was shaking. I thought to myself, ‘How did I get scammed?’ It didn’t make any sense.”

The counselor, who has been in private practice in Colorado for six years, has contacted her bank and filed a police report, but says she has been told there is not much else she can do to recover her money.

The counselor says that throughout the process, she never suspected any fraudulent activity on the part of the “client.” Potential clients have often contacted her via email, she says, and clients have also prepaid for a series of sessions.

In addition, the fake client’s emails didn’t resemble the “Nigerian Prince” scams that have proliferated over email. The counselor says the person posing as the husband with a troubled marriage had an email address with a major Internet provider and that the messages were well-written and detailed. The prospective “client” and the counselor emailed back and forth for weeks.

The LPC says it seemed like this person was somewhat familiar with the counseling profession. He knew the right questions to ask about her services and what they would cover in sessions.

She believes counselors are particularly vulnerable to this type of fraud because they are hard-wired to be empathic helpers. In addition, they are also used to normalizing the abnormal, she says. Because counselors often interact with people who are facing significant life struggles or are mentally ill, they are less likely to question atypical actions such as a person not returning phone calls, sending messages out of the blue or writing an email that is hard to decipher, she explains.

But the experience of being scammed has left her feeling hurt and vulnerable, the counselor says.

“I go out of my way a lot for my clients and sacrifice my time a lot more than I probably should because I want to help somebody,” she says. “I think that’s part of counseling. In order to be empathetic and compassionate to people and promote healing and wellness, a lot of time our time gets sacrificed. … In order to have a business, your clients’ needs sometimes have to come first, if not in line with our own needs.”

The experience does have a silver-ish lining, however. After the reality of the scam settled in, the counselor took time for self-reflection and re-evaluated her business practices. Going forward, she says she will be cautious about screening potential clients and will request information such as an address, an emergency contact number, the name of the client’s primary care doctor and other details before scheduling appointments.

“I would like to try and speak to people on the phone, prior to setting anything up — do phone consultations to validate that they’re real people,” she says.

“I’ve always felt like [counselors are] people who are trying to make the world a better place,” she says. “Why would anyone want to defraud us?”

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ACA members: Facing a dilemma about ethics, business practices or risk management? Contact the ACA Ethics and Professional Standards Department at (800) 347 6647, ext. 321 or email: ethics@counseling.org

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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.

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

Taking it to the extreme: Counseling and adventure sports

By Bethany Bray February 4, 2014

Colin Ward

There is a saying often repeated among people who skydive, bungee jump, white water raft or take part in other adventure sports: “We take risk not to escape life but to keep life from escaping.”

This phrase that encapsulates the adventure sports subculture also shines a light on the disconnect that can occur between counselors and their clients who participate in adventure sports, says Colin Ward, a practicing counselor, counselor educator and mountaineer.

From the outside looking in, adventure sports participants can seem foolhardy, Ward acknowledges. But there is often a strong camaraderie and trust between participants, as well as a deep sense of self-awareness, he says.

“It just looks as if these folks are impulsive, and [people] ask, ‘How can they do that?’” Ward says. “You and your client who is involved in these activities are going to think about risk differently. You just are.”

Adventure sports are defined as activities in which there is a high risk of severe injury or death to participants should something go wrong. Examples include high altitude skiing, bungee jumping, white water rafting or kayaking, skydiving and mountain climbing.

Ward, a core faculty member at Antioch University, started a Seattle-area mental health support network for adventure sports participants roughly two years ago. A practicing counselor for nearly 30 years, he began to focus on the profession’s connection to adventure sports when he took up mountaineering.

Ward and Erin Wenzel, a licensed skydiver and student in Ward’s graduate counseling program at Antioch, have been working on outreach to fellow adventure sports enthusiasts, as well as to counselors, developing ideas about how mental health professionals can “check their bias at the door,” Ward says.

When Ward talks about counselors engaging with people who participate in activities “with a high level of risk,” he emphasizes that he is not referring to adventure-based counseling, which is something entirely different.

Wenzel clarifies further, noting that adventure sports participants may need counseling as they return to their sport after a traumatic injury or accident, or as they grieve the death of a fellow participant or teammate during an outing.

“Adventure sports participants need counselors who are understanding, nonjudgmental, solution-focused, open to handling ambiguity and willing to check their own countertransference about life-threatening recreational activities,” Wenzel says. “We cannot stigmatize these clients as ‘crazy,’ ‘selfish’ or ‘reckless.’ Not only will we miss what committed, passionate, goal-oriented people they tend to be, but we will deny them access to a safe healing space, because once we make them unwelcome in counseling, they will likely never come back.”

Ward contends that a “gap of perception” exists between adventure sports participants and the mental health community.

“[Adventure sports participants] tend to be a bit more autonomous, and reaching out for [mental health] services may not even cross their minds,” he says.

Contrary to what may commonly be believed, adventure sports participants are anything but impulsive, Ward says. In fact, he finds them to be quite the opposite. Most have an orientation toward personal mastery, self-control and goal setting, he says. In addition, they test themselves by adding risk gradually. Ward knows this firsthand; he trained for a full year before going on his first climb. He also points out that they demonstrate a deep level of trust in and reliance on their teammates, who are often on the other end of their climbing ropes or alongside them in a kayak.

These clients will know if a counselor doesn’t “get” the adventure sports culture or stereotypes its participants as impulsive adrenaline junkies, Ward says. “[They] will pick that up in a heartbeat, that ‘this is someone who doesn’t understand my experience,’” he says.

Ward and Wenzel agree that the popularity of adventure sports is growing. For that reason, counselors of all specialties may see participants, Wenzel says. For example, a marriage and family counselor might see a couple struggling with one spouse’s love for a sport — and the risk, time commitment and expense that goes with it.

Numerous membership-based adventure sports organizations are located in the Seattle area. Ward often receives client referrals from these groups. He also provides free introductory sessions to group members as an outreach.

“It behooves mental health professionals to acknowledge that there are distinct approaches and styles to deal with this population,” Ward says. “This is another way we can provide outreach [and] provide a service to our community.”

Things to know: Counseling and adventure sports participants

Don’t attempt to force your perspective on the client, says Ward. Remember that you and your client are going to think about risk differently.
One way adventure sports participants manage stress is by trying additional high-risk activities. They can try out the skills they’re learning — self-control, focus, self-reliance, etc. — with each activity, says Ward.
Many participants will want to return to their sport after an injury, says Wenzel, and counseling can help them do so safely. “Accidents incurred while climbing, skydiving, river rafting, etc., can be very traumatic. The accident is often sudden, painful and unexpected, sometimes leaving permanent damage,” she says. “Processing the trauma with a counselor can help the injured person to make meaning of what happened and mentally prepare for re-engaging with the activity. In skydiving, for example, we often see people return to the sport after an accident and they are absolutely terrified to land. Because the trauma is unresolved, they panic when it’s time to land their parachute and make further errors. As you can imagine, panicking is about the worst thing to do in a life-or-death situation. If they process the event, and maybe learn some tools for relaxation and countering panic-inducing self-talk, we believe that they will be safer during the moments when they really need calm and focus. The task for the counselor is handling their own anxiety or countertransference when a client says they aren’t quitting the activity that perhaps almost killed them.”

Do your homework, says Ward. Get to know the adventure sport that your client participates in, including the jargon and language used in the sport. Read up on the sport and become familiar with its membership organizations.
Don’t be afraid to collaborate with your client. Adventure sports participants are very connected to self-control. “They’re very goal-oriented, so you want to collaborate with them,” says Ward. “Take time to identify small steps and goals toward recovery — something that is going to be right in their wheelhouse.”
“It’s just a matter of tapping into their strengths,” he says. “Most of these folks are coming in with a high sense of self-mastery and are just off kilter with it.”

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A participant’s perspective

After a few tandem jumps, graduate counseling student Erin Wenzel became a licensed skydiver in 2010. She broke her ankle that same year.

“I was everything you might expect an injured adventure sports participant to be: disappointed, frustrated, embarrassed, guilt-ridden and fearful,” she says. “I was suddenly dependent upon people who never really liked the idea of my jumping to help me with basic things, was having nightmares about crashing into the ground and snapping my neck, and had to leave my co-workers hanging while I took time off of work.

“On top of that, I felt like no one really understood what I was going through or what I needed from them. Other skydivers, though very well-intentioned — some of whom had been injured themselves — just naturally assumed I would jump again. My family assumed that I was quitting. I wanted someone to be a neutral, supportive third party and just listen and help me make up my own mind, and I didn’t really have that.

“I’m excited about the possibility of creating more culturally competent counseling for other people who do adventure sports. I have been back to skydiving since the spring of 2011, and it’s a very important part of my life. I want to bring my mental health training to my skydiving community and my skydiving community into the mental health world.”

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Colin Ward and Erin Wenzel will lead a session on counseling and adventure sports at the upcoming ACA Conference & Expo in Honolulu. Their talk, titled “Counseling Adventure Sports Participants: More than ‘Adrenaline Junkies’” will take place March 30. For more information, see counseling.org/conference/hawaii-aca-2014/conf-programs/programs-events.

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For more information

Contact Colin Ward at CWard@antioch.edu

“Why do people skydive?” A first-person blog by skydiver Lori Steffen: nolimitsskydiving.com/skydives/why-do-people-skydive/

Website of the United States Parachute Association: uspa.org

Erin Wenzel’s piece “Mental Health Counseling and Skydiving Trauma” for Parachutist Online: parachutistonline.com/feature/mentai-health-counseling-skydiving-trauma

Personal essay, “Why I Climb” alanarnette.com/stories/whyiclimb.php

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

Follow Counseling Today on twitter @ACA_CTonline