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Addressing problematic internet use with youth and families

By Stephen V. Flynn November 20, 2023

close up of a teenager on their phone; legs crossed; phone in hands

Stock Rocket/Shutterstock.com

Making healthy decisions regarding our screen time and internet use can be challenging and often requires a fair amount of self-discipline. We may ask ourselves, “Why am I looking at my cellphone again?” or “Why did my screen time report go up by 15% this week?” Many families are struggling with these questions and are trying to find unique ways to manage their time online, so the counseling profession should be informed of research-based standards related to helping parents and caregivers with child and adolescent online usage.

Parents of young children and tweens often feel guilty and confused about childhood internet standards and whether it is OK to use screen time as a reinforcer for good behavior or to use the internet as a distraction so that the parents can focus on other tasks. Similarly, parents of teenagers often feel confused about when to give their teen or tween a personal cellphone, when to collect a teen’s phone or tablet so that they focus on homework, and how to discipline their adolescent for inappropriate internet use (e.g., viewing pornography, sharing personal content with strangers, engaging in online bullying).

Counselors may also experience some confusion as to what constitutes healthy and unhealthy internet use, what are appropriate age-based internet standards, what position parents should take in particular areas of adolescent internet use (e.g., pornography, social media, gaming) and how they can work with families to help reduce internet usage when it becomes a problem.

When I bring up the topic of appropriate internet usage in the family counseling class I teach every year, it is the contemporary issue that elicits the most controversy with counseling students representing different generations. Typically, the Gen Xers take a more conservative and concerned stance against excessive internet use, while the millennials and Gen Zers appear somewhat defensive over any criticism related to internet use. As a clinician and supervisor, I often notice the same patterns in clinical practice.

The potential dangers of internet use

Internet addiction is marked by extensive and constant use of the internet despite negative consequences. It should be noted, however, that despite being widely researched and experienced, internet addiction is not a formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders. Nevertheless, it’s important that counselors understand the nuances of internet addiction given the prevalence of technology in modern life.

According to Najah Almukhtar and Saad Alsaad in a 2020 article published in the Journal of Family Medicine and Primary Care, signs of this behavioral addiction include:

  • A loss of control that eventually leads to distress due to spending an excessive amount of time engaging in recreational internet use (e.g., visiting social media sites, surfing the web for information, gaming)
  • Cravings when not using the internet
  • Planning and preoccupation about internet use when not online
  • Functional impairment in daily life
  • A variety of potential physical concerns (e.g., obesity, poor eyesight, carpal tunnel syndrome, headaches, dry eyes, poor sleep patterns, backaches)

Additionally, in a 2015 article in the journal PLoS ONE, Wen Li and colleagues described psychological issues that can emerge because of internet addiction and pathological internet use, including social anxiety, increased attention-deficit/hyperactivity disorder symptomatology, self-injurious behavior, challenges with concentration and sleep deprivation.

A concerning contemporary issue that can be difficult for parents and caregivers to discuss is pornography use by children and adolescents. Hardcore pornography is now available to internet users all the time. According to Paul Wright and Aleksandar Stulhofer in a 2019 article on adolescent pornography use published in Computers in Human Behavior, parents and caregivers often fear how accessible pornography is to children, the content and nature of the pornographic videos being consumed, and youth’s inability to separate fantasy from the facts surrounding most nonpornographic sexual relationships.

In a 2011 article published in Aggressive Behavior, Michele Ybarra and colleagues explored pornography use in youth 10 to 15 years of age and found that long-term intentional exposure to violent X-rated media predicted a nearly sixfold increase in the likelihood of self-reported sexually aggressive behavior. These authors also discovered that deliberate exposure to nonviolent X-rated material was not related to a statistically significant increase in sexually aggressive behavior toward others.

A final area of extreme concern for many parents and caregivers has to do with protecting children from online predators. Adult online predators can deceive and lure youth into sexual encounters, sexually abusive situations, bullying, identity theft and sex trafficking. Common internet-based platforms and devices used by online predators to make contact, socialize, and eventually exploit children and adolescents include social media sites, cellphones, chat rooms, video game consoles, apps and app-based video games, and instant messaging. These platforms allow predators to access potential victims in an anonymous, distant and discreet manner to increase the opportunity for deception and manipulation.

Establishing healthy boundaries with internet use

Problematic use of the internet has the potential to devastate lives and cause significant distress within youth and families. Yet excessive, dangerous and illegal internet behavior remains largely unregulated by the government, and the monitoring and responsibility of appropriate child and adolescent use fall to parents and caregivers.

Counselors are in a unique position to support youth and parents when it comes to issues related to the internet. There are a wide range of potential modalities, theories and interventions to assist in problematic internet use. Parent counseling, family counseling, cognitive behavior therapy, reality therapy, family meetings, psychoeducation, collaborative homework, motivational interviewing and the use of third-party parental control apps are useful in exploring or reducing screen time usage and for protecting youth from potentially harmful sites and images.

Psychoeducation centered on educating families on the potential negative effects of excessive screen time use can be extremely important. Counselors can broach this topic when discussing family rules for internet use. For example, the following conversation is a hypothetical parent counseling exchange between a practitioner and two parents (Lisa and Frederick) who are concerned about their children’s screen use. Although this example is focused on a parent counseling experience, a similar conversation could take place during a family counseling session or during a parental consultation session.

Counselor: You are fearful that screens are serving as a substitute for parenting. I wonder if you’ve considered creating boundaries around when your children are permitted to use their cellphones.

Lisa: I think that’s a great idea.

Frederick: Right now, we don’t have anything formal in place, and their grades are poor.

Counselor: A good area to start is discussing when they should put their devices away.

Lisa: The two older boys typically start homework around 7 p.m., so that would be a good time to collect their cellphones.

Counselor: When would you give them their phones back?

Lisa: Before they head off to school.

Frederick: Let’s say 7 a.m.

Counselor: Some families have different screen time rules for the weekends. What are your thoughts?

Frederick: I think they can have their phones at 5 p.m. on the weekend. We can collect them before they go to bed.

Lisa: Agreed.

There is general agreement that complete avoidance of the internet should not be the goal of treatment. The goals should be more in line with helping parents and youth use the internet safely and responsibly and find a sense of balance and control with using the internet.

Counselors can provide families with referral sites, such as the Center for Internet Addiction and the Center for Internet and Technology Addiction, that provide helpful information and support on technology use.

Screen time issues can also be addressed in a collaborative family homework assignment. In the example of Lisa and Frederick, the counselor may work with them to establish a plan for screen use and ask them to implement it at home:

Counselor: It sounds like the family is continuing to consider a healthier screen time schedule.

Lisa: Yes, do you have any suggestions for us?

Counselor: It sounds like you have already created an initial setup. The two older brothers, Philippe and Anthony, have agreed to curb their usage and increase their homework time by handing in their cellphones at 7 p.m. every weekday evening.

Frederick: That would work for the two teenagers, but what about Ariel?

Counselor: As a 5-year-old, Ariel doesn’t really need much screen time, and it isn’t all that healthy for her. The previous discussion centered on allowing her to watch weekend cartoons and one movie.

Lisa: Sounds like we have a plan.

Frederick: Sounds fine.

Counselor: OK, let’s agree to follow these standards for the upcoming week. During our next session, I’ll check in to see how it all went.

Parents and caregivers often worry how internet use may affect children’s safety, mental and physical health and social development. These example conversations illustrate how counselors can help caregivers establish healthy, age-appropriate rules regarding internet and screen use and facilitate productive conversations when their child witnesses something disturbing such as extreme violence or pornography.

Considering the clients’ developmental level

Counselors must consider the clients’ development level and needs when assessing and treating problematic internet use. When working with adults, counselors should educate them on the addictive nature of the internet, increase awareness around how internet use is affecting their life (e.g., career, relationships, happiness, finances), reduce any shame or blame related to internet use, explore alternative non-internet activities and encourage the person struggling with problematic internet usage to find coping skills and a safe person to talk with (other than the counselor). Unlike children and adolescents, adults often have a much greater capacity for personal responsibility, introspection, self-awareness and self-discipline. This is an important factor to consider when collaborating on out-of-session work related to issues such as reducing screen time and refraining from engaging in certain websites.

Counselors who specialize in working with children, however, should recognize that issues such as awareness, personal responsibility, introspection, self-discipline and difficulty resisting the addictive nature of the internet can serve as barriers to children limiting their own internet use.

If possible, counselors should ensure that parents and caregivers are part of the treatment. This can come in the form of weekly or biweekly parental consultations or periodic check-ins. During these meetings, parents can discuss strategies and goals for reducing screen time. Counselors should also empower parents to create rules that promote healthy screen time usage. General guidelines on children’s media use and family tools can be found on the American Academy of Pediatrics website and on the World Health Organization’s website.

Counselors should remind parents that the shape and scope of internet usage changes for adolescents and that parental flexibility is key. Screen time for teenagers often includes doing schoolwork and projects, watching TV shows, streaming videos, creating art or music online, gaming, connecting with peers via social media and watching fast stimulation online content (e.g., TikTok). Because a lot of teenagers’ screen use involves addictive mediums such as apps, gaming and social media, parents should recognize that their adolescent children can be tempted to spend far too much time online. This heavy usage can cause a variety of negative consequences, such as sedentary lifestyle, obesity and mental health issues.

Establishing healthy rules around technology can be challenging because families often include youth living together who are of different ages and at different developmental levels. Counselors can help parents balance general household standards and rules (e.g., no pornography, no computers after 9 p.m.) with more specified internet usage rules relevant to each child’s developmental level. Although many internet-based parenting issues and supervision concerns can be solved if computers are kept in a common area, this might not be possible for older teenagers who require more independence and have personal cellphones.

Counselors may feel overwhelmed with the balance of encouraging developmentally appropriate independence and helping parents with household expectations regarding devices. While there is no quick and easy solution to this issue, working with families to try to have achievable expectations and to blend family rules with individually tailored expectations appears to be key to long-term therapeutic success.

Issues involving inappropriate internet use, screen time standards and protection from individuals who exploit youth online are not new concerns. Counselors need to be aware of the various issues and problematic behavior that can affect those who are addicted to or abuse the internet. Our efforts as counselors should be centered not only on openly exploring and processing these concerns but also on actively engaging with individuals, families and communities to develop standards for healthy internet use.


Learn more about working with families on issues related to internet use in Flynn’s latest book, The Couple, Marriage, and Family Practitioner: Contemporary Issues, Interventions, and Skills. This comprehensive guide examines contemporary issues, theories, interventions and skills related to working in the interrelated fields of family, couple and child-based counseling.


headshot of Stephen Flynn


Stephen V. Flynn is a professor of counselor education, a research fellow, the founding director of the marriage and family therapy program, and the play therapy program coordinator at Plymouth State University in Plymouth, New Hampshire. He is a licensed professional counselor (Colorado), a licensed marriage and family therapist (Colorado and New Hampshire), a national certified counselor, an approved clinical supervisor, an American Association for Marriage and Family Therapy (AAMFT) Clinical Fellow and an AAMFT Approved Supervisor.

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.

Mental health apps as therapeutic tools

By Lisa R. Rhodes April 5, 2023

A hand holding a smartphone with an app opened asking "How are you feeling?" and five emojis indicating various moods. Beside them is a cup of coffee and an opened laptop.


Many people today rely to some degree on apps in their efforts to establish a sense of personal wellness. This has led some professional counselors to consider the use of select mental health apps with clients to help them reduce stress and counter their negative thoughts and emotions. 

Jennifer Hart, a licensed professional counselor (LPC) in Wyncote, Pennsylvania, and Sarah Barry, a licensed clinical professional counselor in Butte, Montana, are using mental health apps both virtually and in person with their clients.  

Hart believes “the possibilities are endless” in using these digital resources as supplemental tools in clients’ journey of mental health and recovery.  

“Whenever someone is trying to implement change into their life, the easier it is to access the information, the more likely it is that a client will do the homework or work on implementing the changes,” she says. “No one wants to jump through hoops to do hard work. But if you can easily access items to help you do the work behaviorally, it’s more likely to get done.” 

Security precautions 

In their book Doing Counseling: Developing Your Clinical Skills and Style, published by the American Counseling Association earlier this year, Jude T. Austin ll and Julius A. Austin, advise counselors to “choose apps that can properly secure client data and support therapeutic options that are based on scientific evidence while also upholding ethical standards of conduct.” 

Hart, who works at McPherson Clinical and Counseling Services, says her clients use a variety of apps, including Calm, Headspace, Mindfulness Bell, Word Search, Adult Coloring, Sparkle, Kindle and Audible, to help them manage their anxiety and depression or to assist them with emotional regulation and lifestyle changes. However, Hart uses mental health apps with her clients selectively and ensures that she makes careful notations concerning what mental health concerns she and the client are working on by using the app. She also notes how the app fits into a client’s overall treatment plan.  

Hart’s clients largely report that they enjoy using these apps because of their accessibility, which factors in to helping some clients make progress in their therapeutic outcomes. 

“Clients report feeling better, [having] less symptoms of anxiety, better sleep, better relationships and [a] better quality of life,” she notes. 

Supplemental tools 

Barry, owner of Mountain of Hope Counseling LLC uses the CBT Thought Diary app to help raise clients’ awareness of their thoughts, emotions and behaviors. The app assists clients with reducing their stress levels, tracking their moods and changing negative thought patterns. 

Among the tools the app provides is a thought log that allows clients to type in whatever thoughts they are having throughout the day. Barry and the client will then review the log in session and discuss whether they notice any connections between the client’s thoughts and their feelings of anxiety or depression. 

Barry says the CBT Thought Diary app is helpful because clients can use it on their own time and whenever they feel triggered by an emotion. 

The Calm app is also beneficial for clients who are experiencing depressive symptoms, Barry notes, because it helps them incorporate mindfulness and breathing exercises into their day.  

“In my experience, someone who is struggling with depression also shows features of anxiety, so if a person is able to utilize deep breathing exercises with calm meditation, they are able to learn to cope in the moment without having these emotions build up and [having to] wait to process it all during their therapy appointments,” Barry explains. “It enables the individual to work toward their own healing, which builds self-esteem and resilience.” 

Jessica Eiseman, an LPC supervisor at Ajana Therapy and Clinical Services in Houston, says mental health apps can be useful tools in either in-person or online therapy. However, she emphasizes that they are only tools and should not be used as a substitute for actual therapy. 

“These should be supplemental to the work someone is already doing with a counselor,” Eiseman says. “Without the guidance of trained mental health professionals, like counselors, information can be misused or misinterpreted.” 

For example, Eiseman says that while a meditation app may help to reduce some symptoms of certain mental health disorders or provide some temporary relief, it is unlikely to treat the totality of the client’s symptoms. 

The Austins say that using extra online resources with clients can be helpful to create visuals, watch videos, listen to music, draw live genograms and draw cybernetic patterns. But they remind counselors that “the point of a technique is to transcend the technique.” 

“If we want a client to process grief, using an app is not going to help them process grief,” the Austins stress in a joint email response to Counseling Today. “It may assist, but the processing needs to take priority. The dangers are when counselors become reliant on apps or technology to do the work. This is the same with any intervention. What makes the Myers-Briggs [Type] Indicator so effective is not the assessment itself, but the processing afterward. The same is true for apps in session.”  


The following resources may be helpful for counselors who would like to learn more about mental health apps and issues of privacy and security:  

 Read more on telebehavioral health and clinical practice in Counseling Today’s April cover story. 



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

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

The impact of telebehavioral health on clinical practice

By Lisa R. Rhodes April 4, 2023

A Black woman sits on a chair with a laptop; her hands are in front of her chest, palms together

denis kalinichenko/Shutterstock.com

Just a few years ago, telebehavioral health was not a service that many counselors provided for their clients. Jennifer Nivin Williamson and Daniel G. Williamson, both licensed professional counselors (LPCs) and core faculty at Capella University, say that the use of technology in counseling before the COVID-19 pandemic was often considered “avant-garde” or a “fringe” practice.

The Williamsons note that telebehavioral health was seldom billable and often considered risky, with a few exceptions such as distance counseling for military families.

But the reticence toward telebehavioral health services in the mental health field changed when COVID-19 hit the nation. Because of the national public health emergency, the Department of Health and Human Services Office for Civil Rights temporarily eased the restrictions of the Health Insurance Portability and Accountability Act (HIPAA), allowing mental health providers to more easily provide telebehavioral health services. (For an update on the HIPAA compliance rules for telebehavioral health, see the Risk Management for Counselors column on p. 10.)

This meant a lot of counselors had to learn how to use telebehavioral health whether they wanted to or not. “When the pandemic-mandated general shutdown occurred, there was no other choice but to do it [therapy] virtually for most people. Very few therapists would risk going into the office,” says Sam Lee, an LPC at the McLean Counseling Center in McLean, Virginia. “Some therapists, mostly the older demographic, resisted [going] virtual. Some clients were unhappy about having to do therapy virtually, but it was that or none.”

Some clients missed the physical face-to-face immediacy of in-person therapy and others questioned if virtual, on-screen counseling would really work, he adds.

But the increase in people seeking mental health services during the pandemic made telebehavioral health a viable alternative to traditional therapy, and now telebehavioral health seems to be here to stay.

“Most people have gotten so used to the online interactions because of the pandemic that it is integrated into our everyday lives in a way it hadn’t been prior to the pandemic,” says Jessica Eiseman, an LPC supervisor in Texas.

And the majority of people who receive online health care have a positive view of online therapy. According to the COVID-19 Telehealth Impact Study, a collaboration between the American Medical Association and the COVID-19 Healthcare Coalition, 79% of the patients who were surveyed in 2021 said they were very satisfied with the care they received during their last telehealth visit, and 73% said they would continue to use telehealth services in the future.

Research has also found that telebehavioral health is effective in treating some mental health disorders. A meta-analysis published in the Journal of Anxiety Disorders in 2018 found that in-person, traditional cognitive behavior therapy (CBT), internet-delivered CBT and bibliotherapy have equally effective outcomes in treating people with anxiety and depression.

Although adapting to telebehavioral health has been easy for some counselors and challenging for others, it has caused many clinicians to rethink how they use clinical skills designed for in-person therapy and gain new skills when building the therapeutic relationship, assessing clients and using therapeutic techniques in an online environment.

Expanding the reach

Telebehavioral health has also made therapy an option for people who might have never entered a counselor’s office otherwise. Jude T. Austin II and Julius A. Austin, co-authors of the book Doing Counseling: Developing Your Clinical Skills and Style, published by the American Counseling Association earlier this year, say clients struggling with social stigma can use distance counseling as “a jumping-off point for more fulfilling social interactions.”

“We have both worked with clients who start off only doing phone sessions, then they gradually move to virtual sessions, then in-person sessions, then group sessions. Distance counseling makes counseling accessible,” says Jude Austin, an assistant professor and clinical coordinator in the counseling program at the University of Mary Hardin-Baylor. (For a discussion on possible issues with access and telebehavioral health, see Chris Gamble’s article, “Rethinking the accessibility of digital mental health” in the July 2022 issue of Counseling Today.)

Distance counseling can also be a first step in mental health treatment for people of color who may want to seek help but don’t have the time to visit a therapist. “We grew up in a community where counseling was very much a ‘white people thing,’” says Julius Austin, an assistant professor in the clinical mental health counseling graduate program at Grand Canyon University. “It was not that Black, Indigenous and people of color [BIPOC] individuals in our community didn’t value mental health or find processing through life important. It’s just that no one had [the] time or resources for counseling; not to mention that finding a BIPOC counselor when and where we grew up was difficult.”

“Distance counseling is a game-changer for populations who understand the importance of counseling but never had the time or struggled to find a therapist they felt comfortable approaching,” says Jude Austin, an LPC and licensed marriage and family therapist with a private practice in Belton, Texas.

It can also remove barriers that prevent some clients from taking the first step toward getting help, Jude and Julius Austin add. For example, they note that a queer quarterback who doesn’t want to go to the university counseling center out of fear of being stigmatized or a BIPOC individual who does not see themselves represented by the counselors in their area can decide to reach out to a counselor in a surrounding city by making a telebehavioral health appointment. Similarly, a construction worker who wants to save their marriage but can’t find the time to go to counseling can now have a Zoom or phone session with a counselor during their lunch break.

“There has been a lot of work done by ACA, counselors themselves and clients to lower the stigma of seeking counseling,” says Julius Austin, an LPC and the clinical director of a community-based private practice in Lafayette, Louisiana. “Distance counseling can serve the ‘let me just see what this is all about’ population of clients who think counseling can be beneficial but they don’t necessarily know if they will like it. They just want to explore counseling.”

Adapting to the technology

With so many counselors providing telebehavioral health for the first time during the pandemic, training became essential. Jennifer Hart, an LPC who provides hybrid services at McPherson Clinical and Counseling Services in Wyncote, Pennsylvania, admits she was not comfortable with using technology at the start of the pandemic, so she had a steep learning curve.

“I am a somatic-oriented practitioner, meaning I am very keen to body language and physiological responses when having sessions,” she says. “Not having in-person sessions really changed how I assess and [develop a] treatment plan. It was tricky. But with time and training, using technology to provide care became easier and easier.”

Hart received one hour of telebehavioral health training from a former employer. The training included how to use the practice’s telebehavioral health platform and how to use apps on iOS and Android devices. (For more on the use of mental health apps, read the Counseling Today articles “Mental health apps as therapeutic tools” and “Using apps to promote client safety.”)

When the pandemic began, the counseling practice Lee was working at provided training for the employees on how to use the technology for virtual counseling. “We were guided by emails by the practice administration on how to set up [a] virtual platform to restart seeing clients at home through telehealth,” he says. “There were trepidations, but at least for me, it was not really a hassle.”

Jude and Julius Austin have used some form of distance counseling in their work with clients since they each opened their private practices five years ago, but it became a primary modality during the pandemic lockdown. They both learned how to use telebehavioral health technology through various continuing education opportunities and from multiple conversations with the IT support staff working for the virtual platform and smart devices that the Austins use. For example, the Austins say they reached out to Zoom and Apple support to learn how to make a breakout room, how to create meeting templates and how to set up virtual private networks — all the technical things they didn’t have time to learn in graduate or doctoral school.

Sarah Barry, a licensed clinical professional counselor and owner of Mountain of Hope Counseling LLC in Butte, Montana, where she provides hybrid services for clients, says the specialized training on telebehavioral health that she received at the beginning of the pandemic helped her easily adapt the technology. She received nine synchronous video continuing education credits through the University of Holy Cross while she was living in Louisiana before the pandemic as a part of a state requirement to provide certified telehealth services.

Jennifer and Daniel Williamson, co-editors of the ACA book Distance Counseling and Supervision: A Guide for Mental Health Clinicians, say that before the pandemic, they only saw clients in person at their private practice, PAX Consulting and Counseling PLLC in Waco, Texas. But when their building closed for six months during lockdown, they had to rethink how they were going to see clients. They converted their practice completely to distance counseling using a HIPAA-compliant synchronous video conferencing platform, and they provided practice sessions and technological assistance for any clients who were hesitant about trying this new platform.

“Eventually, they [clients] began to love this approach because of the convenience. They were able to continue sessions when quarantined, especially when gas prices were hovering around $5 per gallon and [when] the weather was inclement,” the Williamsons add.

They say working in distance education and in other technical roles, as well as their previous experience with technology, made it easier for them to transition to virtual counseling. Daniel Williamson, for instance, has served as the webmaster for the School of Education at Baylor University and has experience working in electronic commerce.

The combination of counselor training, technology training and the implementation of counseling services using technology has been a huge help, the Williamsons note. They are currently completing the requirements for the board certified-telemental health provider credential, which covers the basics of telehealth and was developed in 2018 by the Center for Credentialing & Education, an affiliate of the National Board for Certified Counselors.

Now that their clients are comfortable with telebehavioral health, the Williamsons say they have no plans to return to a physical location.

Building rapport virtually

Forming a trusting and empathic therapeutic relationship with clients is “at the heart of counseling,” says Eiseman, founder and clinical director at Ajana Therapy and Clinical Services in Houston. The relationship is the “biggest influence on the effectiveness of counseling,” she stresses, adding that this is true no matter if the session is in person or virtual. “Our authenticity should be able to come across to our clients no matter the setting. I try to make my clients feel as comfortable as possible, whether I sit in the same room or on a screen,” she adds.

In a telebehavioral health session, it may not be easy for counselors to see a client’s body language, so Eiseman suggests counselors pay more attention to aspects of nonverbal communication. For example, counselors can watch to see if a client is holding their breath when they talk about a particular event. Are they holding their hand over their chest or heart while they are talking? Are they biting their lips out of nervousness?

“After building rapport with clients, you learn the micro expressions that can help you identify movements or reactions they may have throughout their sessions,” says Eiseman. “At times, you may even learn how to keep track of someone’s breathing patterns on camera, which can be very helpful in sessions, especially with somatic work.”

Lee says when he is working with a new client in distance counseling, he follows all the clinical guidelines he learned for treating in-person clients, such as assessing the client’s cognitive and emotional state at the beginning of the session. He also does a friendly check-in by chatting with a client to break the ice, and he makes sure he expresses empathy in areas where the client is focusing their emotions.

“I ask every new client if they had previous counseling experience, and if it was in person or virtual,” Lee says. If it is their first time in a virtual session, he explains the challenges (e.g., initial unfamiliarity/discomfort about virtual therapeutic interaction, internet connectivity issues, a potential for electronic security issues) and benefits (e.g., more flexibility with scheduling).

If appropriate, Lee says he may comment on the background decor of a client’s room or space, such as paintings and posters on the wall, and share his own similar taste in art or an experience from his life regarding the posters. Discussing common interests helps counselors make a personal connection with clients, he explains.

Barry finds that engaging in active listening, including repeating client concerns and making eye contact, helps develop a solid rapport with clients and makes them feel comfortable. “Eye contact during telehealth is extremely important so the client can know you are engaged in the session. Eye contact is a sign of active listening and displays attentiveness during the session, which helps build the therapeutic relationship,” she says. “I’ve had previous clients tell me [about] their frustration with other telehealth experiences in which they felt the provider was looking at their cell phone and/or toggling through webpages, which caused the client not to feel prioritized during the session and to seek out treatment from another provider. As helpers, we need to be engaged in the therapeutic process as much as possible.”

It is also important for the provider to be attuned to cultural differences in which eye contact may not be the strongest form of communication for the client or the provider, adds Barry, who is also an LPC in Louisiana.

Barry applauds new clients for their courage and bravery in taking the difficult first step to seek out treatment in a virtual space. “Positive reinforcement helps to develop trust,” she says. And “if my patients, whether through telehealth or in-person counseling, know I am cheering them on every step of the way, I feel this helps them to know I’m a human being just like them. I just happen to be on the other side of a computer.”

Establishing guidelines

Another part of building the therapeutic relationship is for clinicians to talk about the nuts and bolts of conducting telebehavioral health sessions, particularly the security risks of meeting online, confidentiality, appropriate spaces to conduct therapy and the proper attire for a virtual session.

Lee says his practice provides new clients with the general guidelines for informed consent and therapy policy forms using the client portal on SimplePractice. The policies cover the benefits and disadvantages of telebehavioral health, as well as the risks of remotely meeting over a secure teleconferencing platform, the theoretical possibility of a security breach, technological malfunctions and the management of emergency situations. (For more on the specific requirements for informed consent for telebehavioral health, see the first chapter of Distance Counseling and Supervision).

Lee says his practice chooses not to include any formal dress code rules because he has noticed that the way clients dress for a telebehavioral health session can often provide insight into their social functioning.

“No one [has] ever dressed improperly for [a] session in my experience,” he continues. “I always present myself in professional and appropriate attire. [The] attendance and punctuality rules are all the same. I do ask if the client is in a secure setting to ensure privacy and confidentiality if they are at home or [in an] office area.”

Barry tells her clients to treat their telebehavioral health session as if they were going to the doctor. She says she asks them “to be dressed, out of bed and ready to address the issues that are taking place in their lives.”

So far she’s had only one client begin a telebehavioral health session inappropriately dressed: The client was lying in bed in their pajamas and was not fully awake. Barry told the client she was not able to continue the session unless they were fully awake and ready to begin. She asked the client to contact her when they were ready and logged out of the session. The client rejoined the session about 10 minutes later and apologized for not being prepared the first time.

Daniel and Jennifer Williamson remind counselors that they are obligated to provide the same standard of care online as they do in person. “We have heard horror stories of counselors trying to engage a client [who has the] video off while driving a car full of kids,” the Williamsons say. “There are many issues with that scenario. Creating a safe and trusting relationship must begin by creating strong clinical spaces for ourselves and helping our clients create clinical spaces within their own locations.”

For the Williamsons, a clinical space includes the following:

  • Being alone in a room that has a door
  • Having a door that is closed
  • Using a sound machine

They recommend clinicians help clients be creative when defining what a clinical space means for them. When privacy is a challenge, for example, clients can use a closet, bathroom or even a parked car, as long as it is safe. And the “sound machine” could be a radio or television set or a white noise machine.

Defining a clinical space also gives clients emotional permission to advocate for their own privacy, the Williamsons add.

Assessing clients virtually

These counselors interviewed for this article acknowledge that assessing clients virtually can be challenging, but they also say that if counselors remain curious and use their interviewing skills, then virtual assessments can be done properly. In addition, they recommend clinicians consider using virtual platforms that provide tools for clients to self-assess.

Hart admits that assessing clients is one area that has been a learning curve for her. “Because I am a somatic-oriented, body-oriented practitioner, I had to learn how to be more attentive [when assessing clients]. I have a trauma-informed approach too, so at first, I had doubts that I would be able to assess,” she explains.

Hart has also learned to be more inquisitive and exploratory with the client and ask more questions. For example, instead of saying, “I notice that you …,” she now asks, “What do you notice about yourself and your body when you mention this symptom?’”

Hart says she takes a more Rogerian approach to assessments now because it allows clients to become an observer as part of a therapeutic team. “Instead of making first-person observations and verbalizing them, now I teach clients how to be more mindful of their somatic responses,” she explains. “It has worked out well and has created more mindfulness for clients.”

When doing virtual counseling, Lee uses all the same in-person modalities for assessing clients, including motivational interviewing and paying attention to the client’s facial expressions, tone of voice and speech patterns, and body language. And although he can see clients only from their chest up during a virtual session, Lee says he is not missing much in regard to nonverbal communication.

“I can tell enough nuances on face and shoulder postures and movements and can very well see the telltale signs of lethargy or agitation and interest or disinterest as well as I do in person where I can see the entire body,” Lee notes. “What is different in the virtual encounter is the close-up focus of video’s visual framing, which accentuates these clues while, at the same time, the client shows much more of their natural emotional and physiological state in their daily surroundings, unlike being in a doctor’s office.”

The presenting symptoms and the types of online assessment tools the counselors use will help determine the success of a virtual assessment, Eiseman says. She recommends counselors consider online assessment tools such as those provided by Pearson Assessments, which allow clients to assess themselves and submit the assessment for scoring.

Lee and Barry use the SimplePractice virtual platform to assess clients. The platform provides clients with a link to a HIPAA-compliant client portal where they can access assessment forms that screen for depression and anxiety. Clients complete the forms during the intake process and submit them using their own secure portal, and it notifies counselors when the forms are complete.

“It is also important to know the limitations of what you need to assess, as you may need to refer [the client] out if what is best for the client is an in-person assessment,” Eiseman adds.

Jude and Julius Austin say assessing clients often involves counselors using their sixth sense, which is easier to do in person. For example, during an initial intake assessment, a clinician may ask a client about their alcohol usage. “It’s the way they answer that make us intuit that there is something deeper to process in this area,” Julius Austin says. “It could be the heaviness of the client’s voice or the briskness of their responses or their lack of eye contact. Other times, it is the way their feet are shaking or [their] hands are wringing.”

But when assessing clients virtually, it can be difficult for counselors to use their intuition to determine when and if they need to dig deeper. The Austins suggest counselors use themselves as a tool and approach assessments with a “childlike curiosity.” For example, when virtually assessing a client who says they are struggling with anxiety, the clinician can start by examining the client’s choice to use the word struggle. In this situation, the Austins may respond by saying, “What does the word struggle mean to you?” or “What does struggling look like?” And then they would take the same approach with the word anxiety.

“We might share with clients things about their experience that resonate with us. We won’t go into great detail, but we use our experience to deepen the client’s connection to their emotional process in session. If a client feels insignificant, we mentally ask ourselves, ‘When have I felt this way?’” Jude Austin explains. “Instead of processing our experience, we think about the connective emotions and thoughts surrounding our experience, like insecurity, fear and anger. Then we use our experience [to] guide our reflections. As a distance counselor, being curious about our own experience and having emotional courage when sharing can help create the in-person atmosphere when distanced.”

The more counselors use themselves as a tool by sharing aspects of their own experience with clients and approach the process with curiosity, the more they will instinctively use their sixth sense or intuition in this virtual space, the Austins say.

The limitations of virtual therapy

Although proper assessments can help counselors determine whether a client is suited for distance counseling, the counselors interviewed for this article say clinicians should be mindful that some mental health disorders should not be treated using telebehavioral health.

“There are some serious ethical concerns to consider when moving counseling online, but the appropriateness of seeing someone with a serious mental health issue is more nuanced than [whether] in-person or online counseling is better for those clients,” Jude and Julius Austin say. “Nonetheless, we think most counselors can acknowledge that some clients struggling with hallucinations, delusions, self-harming, suicide or homicidal issues need extra considerations.”

The Austins stress, however, that counseling is now being done in “all sorts of nontraditional, personalized and practical ways.” As a result, they say whether a client with a serious mental illness can be treated online depends on the situation and the creativity of the counselor.

The Austins advise their peers to use their clinical judgment rather than a sense of fear as a guide when helping any client to gain the most from counseling.

Eiseman says counselors should look for aspects about their clients that may make virtual therapy more difficult, or even potentially harmful. “Even if a client tells you that they feel comfortable with virtual sessions, it is still our duty to assess that online therapy is right for the client based on our clinical opinion,” she stresses.

Therapeutic interventions in virtual sessions

Counselors can use many traditional therapeutic approaches without having to adapt them for distance counseling. “I don’t have to alter therapeutic techniques like CBT, dialectical behavior therapy, and acceptance and commitment therapy because they are empirically based theories that have existed for decades and therefore have more virtual resources available,” Eiseman says.

CBT is the backbone of Lee’s work. He says virtual clients learn to identify cognitive distortions and correction skills in the same way clients do in person.

One advantage in using distance counseling, Lee says, is the opportunity to see and interact with clients in their personal surroundings. Viewing clients on their “home turf” often gives him insight into their lifestyle, personality, socioeconomic status and even what kind of neighborhood they live in, and he says that these insights can help in a client’s treatment. For instance, he once worked with a married couple who were struggling with a hoarding issue. They initially came to therapy for relationship issues, but as the therapeutic trust was building, the clients were willing to show him their entire living space using a laptop camera, which allowed Lee to see the exact nature of their hoarding. He worked with them during their sessions in real time to catalogue the accumulation and their piling and storage patterns, and he helped them strengthen their reorganization skills so they could reduce their tendency to hoard materials while still being able to access what they needed. By being supported and held visually accountable through the virtual sessions to adhere to the treatment plan, the clients were highly motivated to implement both short- and long-term goals, which improved their standard of living and their relationships, Lee adds.

Barry says she uses the SimplePractice platform’s whiteboard to help virtual clients process feelings of anxiety or depression. She draws the CBT model on the whiteboard during a virtual session and works with clients to help them understand how their thoughts and behaviors work together to create an anxious or depressed state.

“The whiteboard really helps them to see a technique visually, so we are able to interact together,” she says.

Although most therapeutic approaches can be used with clients in person or in a virtual setting, some therapeutic techniques, such as play therapy, exposure therapy, brainspotting and ecotherapy, are not suited for distance counseling, Eiseman adds. Play therapy, for example, relies on the use of tangible items such as sand trays and toys. Although this can be done virtually, she finds it difficult to engage clients in the same way using virtual sand trays compared with in-person counseling. And brainspotting may require the client to have special equipment set up in their home to do it online, she says.

Looking forward

To stay abreast of technological advances and ensure that they are learning to properly integrate in-person counseling skills into virtual counseling, clinicians should continue to seek additional training opportunities. And graduate counseling programs must be intentional about including online therapy in their curricula.

“As this is a new modality for treatment and is gaining more attention and appreciation from both providers and clients, there is growing interest in bolstering educational training,” Jennifer and Daniel Williamson note. “Just prior to the pandemic, it was attended to as much as it now needs to be.”

Graduate counseling programs need to ensure that they train “counselors and supervisors to do distance work ethically and skillfully,” Jude Austin adds. “The more complicated answer is shifting the culture of distance counseling from convenience to a modality with just as [many] nuances as other modalities.”

As a counseling supervisor, Eiseman says all her students and employees are required to complete training on the best practices of telebehavioral health and HIPAA compliance. She also supports digital mental health training in graduate school programs.

“It is also my responsibility as a supervisor to stay up to date on any rules or regulations regarding digital mental health practices, as well as [to] model and teach appropriate practices,” she adds.

Because states may have different rules and regulations for the encrypted programs used in virtual counseling or for online communications and reciprocity, Jude and Julius Austin advise counselors to be aware of the rules their state licensing boards have for providing telebehavioral health services in other states.

In many ways, new counseling graduates are “stepping into a profession that might seem a bit like the Wild Wild West” regarding the guidelines for telebehavioral health, the Austins say. “States have different rules. Some have reciprocity; some don’t. Some are ‘duty to warn’ states and others are not. Some states make counselors wait what seems an arbitrary five years to get to a supervisor status; others have less time.”

The counselors interviewed for this article also say that as telebehavioral health continues to evolve, the counseling profession can play an important part in developing new technologies for its practice. Important legal, ethical and clinical standards of care will likely be left out of the equation if counselors aren’t involved in the decisions around telebehavioral health, Eiseman notes.

Jude and Julius Austin agree. “Counselors should be involved in innovation. Our trained ears, hearts and minds can help shape technology to suit healthy therapeutic relationships,” they say. “Being a part of innovation can also put us in a position to advocate for ourselves as some digital mental health platforms can be a bit predatory and unfair to counselors and clients.”

Hart also thinks that counselors can be the pulse of telebehavioral health in the future. “I think that compassion and empathy — these two very human traits — are rarely found in technology alone,” she says. “If we can bring about more ways to display these human traits within technology, that would be helpful.”

hand holding phone with an image of a person sitting, knees to chest, arms across their legs. Text above the phone reads, "Need help?"

Nadia Snopek/Shutterstock.com

Preparing for virtual emergencies

Securing a client’s safety is a critical step when engaging in telebehavioral health sessions. After a counselor determines that distance counseling is appropriate for the client, they need to work with the client during the intake process to create a safety plan in case the client experiences a crisis during the virtual session. The plan should include the following:

  • An emergency telebehavioral health consent form. This form outlines what would happen if a client had an emergency or crisis while being treated virtually, says Jessica Eiseman, a licensed professional counselor supervisor at Ajana Therapy and Clinical Services in Houston. It provides the counselor with an emergency contact and gives the counselor permission to call that contact in the event of an emergency.
  • A list of emergency resources. Jennifer Nivin Williamson and Daniel G. Williamson, licensed professional counselors and core faculty at Capella University, say this list should include an emergency contact person — someone who is within 5-10 minutes of the client, the client’s doctors, the client’s medical conditions and the first responders in the area. Jude T. Austin II and Julius A. Austin, licensed professional counselors and counselor educators at the University of Mary Hardin-Baylor and Grand Canyon University, respectively, add that the list can also include a local hospital and police station and the name and contact information of a local counselor or other colleague who is willing to see the client in person, if necessary, during an emergency.

Eiseman reminds counselors to always verify a client’s location when they are in a telebehavioral health session. If that location is not a client’s residence, it is important to get the address of where they are during the session. The Williamsons also recommend counselors document the client’s location in the case notes for every online session.


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

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

The benefits of a multisensory experience in therapy

By Ashley Heintzelman February 14, 2023

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

Studio Romantic/Shutterstock.com

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

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

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

Finding the right fit

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

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

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

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

A multisensory experience

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

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

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

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

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

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

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

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

Incorporating sensory elements with clients

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

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

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

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


photo of Ashley Heintzelman


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

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

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

Embracing fandom in counseling

By Samantha Cooper November 7, 2022

Fan communities, or fandoms, are often misunderstood by the public. Fandoms refers to people who share a common interest in an aspect of popular culture. Whether they are huge fans of the Marvel Cinematic Universe or enjoy dressing as anthropomorphic animal characters, also known as “furries,” people who dedicate their free time to a specific piece of media are often seen as “odd” or childish to others.

For example, according to a 2017 article published in Psychology Today, some people consider furries’ desire to dress as animals as a form of sexual gratification, rather than a form of self-expression. In the case of fans of fictional franchises, such as the British science-fiction TV series Doctor Who, the negativity seems to come from a long-established idea that these fans are social misfits and outcasts and that they place more importance on their fictional world rather than reality.

Being a fan of a certain sport or sports team, however, is seen as more socially acceptable and often isn’t considered to be a “fandom” in the same way pop culture fiction is. But even as science fiction, fantasy and superhero franchises become more mainstream in pop culture, those who are deeply enmeshed in fandom culture may still feel as though their passions won’t be properly understood by mental health professionals because of these stigmas.

“Speaking as a science fiction geek myself — I even have a Star Trek tattoo — this subject is really close to my heart. Empathy is important when supporting any therapy client, but because there can be some stigma around fandom communities, empathy is important when supporting fandom clients. If the therapist is coming from a perspective that perpetuates stigma, such as looking down on furry cosplay artists or fanfiction authors, it’s important for the therapist to do the inner work, to grow as a person, to learn how to see the joy in others’ joy,” says Lindsay Meagher, a licensed mental health counselor at Protea Wellness in Seattle. “It’s important to internally approach fandom clients from an open-hearted, open-minded, empathic perspective.”

Using fandom to build rapport

Some counselors embrace “geek therapy,” which integrates aspects of so-called “nerd culture” such as video games, comic books and science fiction media to build rapport with clients.

Geek therapy operates on the principle of affinity, which is using common interests or background to establish a repertoire with a client. If a counselor mentions they share an interest in a particular piece of media or a love of going to fan conventions, the client can feel more comfortable expressing this part of their identity.

Ashley Myhre, a licensed marriage and family therapist at POW! Psychotherapy in Minneapolis, says it’s important for clinicians who are working with this population to create spaces where the clients can feel safe to express themselves.

Myhre has created her practice around the idea of fandom therapy. The logo for her private practice resembles a sound-effect bubble from comic books: It’s a light blue bubble with the word “pow” written in orange, capital letters. She says this design choice helps communicate that her practice is one where clients can bring their whole self to sessions.

“If that’s the kind of client you want to cater to, you need to make your space welcoming,” she explains. Her office space is decorated with rainbow flags, pop culture figurines and stuffed animals, which are images that signal to her clients that her practice is a safe space for people in LGBTQ+ and fandom communities. Her website also contains a statement saying, “Mental health for nerds, geeks, misfits and others outside of the mainstream.”

Counselors who aren’t a part of fan communities can still show their support in small ways, Myhre notes. For instance, she says that little things such as office decorations can make or break a client’s trust. “Do you have any kind of fan art in your spaces? Is your mug from your favorite TV show? What are [some] visual cues you can be sending to clients that it’s a safe space?” she asks.

Counselors can also find ways to learn about fandom and use this knowledge to build rapport with clients. It’s much easier to make your space welcoming to those in fandoms when you understand the basics, Myhre says. And part of that can be done simply by listening to and respecting clients’ passions.

Myhre advises counselors to listen for cues where the client is talking super passionately about some aspect of fandom such as a particular character or object. When she hears this, she will ask the client questions such as “How has this mirrored some of your own experiences?” “How have you come to better understand yourself through being a fan of this media?” “What are the strengths you see in these characters that you want to bring into your own life?” or “How does this align with your values?”

Doc Davis, a licensed professional counselor and owner of Side Quest Therapy in Austin, Texas, takes this a step further by incorporating games, such as video games or online chess, into counseling sessions. This is the approach he takes with one of his clients; he always begins their virtual counseling session by playing a video game together.

“We start our sessions literally online together playing a game,” Davis explains. “We’re not talking about therapy just yet; we’re just playing a game, … having fun, and then the therapy starts to slip in.” When the conversation starts to be less about the game and starts becoming more about the client’s life, Davis puts the game on pause, and they continue the conversation and move into the therapeutic part of the session.

Kashawn Hernandez/Unsplash.com

Finding a sense of community

Fandom can also provide a sense of community. Those who struggle to connect with others in real-life communities may find their companions online or in person through a shared love of a piece of media. For people who struggle to make friends, outwardly expressing their fandom makes for an easy icebreaker. Two people wearing the same shirt, for example, can strike up a conversation and form a friendship based on their mutual interest.

Meagher says that while anybody can potentially be drawn to fandom cultures, people on the autism spectrum are often drawn to fandoms. “A lot of fandoms and a lot of passions are autistic special interests,” says Meagher, who is autistic. “Many of us in the autistic community lean into our passions in really beautiful ways that are part of the community’s norms, but that can be jarring for a lot of people outside of the autistic community who maybe don’t engage with the world in that way.”

People in fandom often use social media platforms to connect with each other. Both Facebook and Reddit allow people to join different groups devoted to fandoms, and there are several hashtags that make it easy to find people who share similar fandom interests.

“I know that social media has helped people who are isolated, often as a result of physical disabilities like fibromyalgia, or as a result of being in grad school. … Often people in fandoms are seeking friendship with people that they have something in common with, and it can be a little hard sometimes to make local friends quickly who share in one’s passions, so this makes online social spaces, such as Archive of Our Own, Discord, Instagram, Tumblr, and even Facebook and Twitter, really lifesaving for a lot of us,” Meagher says.

Therefore, it’s important for counselors to recognize the role that fandoms play in people’s lives, and the different aspect and nuances that come along with it, including the prevalence of parasocial relationships, which are one-sided relationships that someone forms with a media persona. (For more on parasocial relationships, see the sidebar below.)

People involved in fandom often consider themselves to be their own community — one with a shared interest. So having a therapist who is also familiar with the concept and importance of fandoms will make a client more comfortable in the therapeutic environment.

“I think if you’re in fandom, you get it. We have this shared experience. … It just makes things so much easier,” Myhre says.

Just knowing that fandoms are valid communities and becoming curious about a client’s passion is a good start and helps counselors connect with this population. Counselors can also consider where their own “geeky” interests lie and make those interests known to their clients, Myhre adds.

Davis agrees that counselors should be open to exploring aspects of fandom that interest them. The name of his private practice, Side Quest Therapy, is a reference that is instantly recognizable to people who play video or tabletop games. It shows that he’s more than a therapist who just happens to play games, he says. It shows that he integrates it into his clinical work.

Counselors, of course, can’t be a fan of everything, so they will encounter clients with different interests. When Myhre has a client who has an interest she isn’t familiar with — such as a particular anime — she’ll watch a few episodes so she can learn a little bit about it and be able to connect better with the client. For example, she may ask, “What are you getting from anime? Is this particular story connecting with you? Are you bringing some of the lessons into your own life?”

Myhre, Davis and Meagher agree that the most important thing is for counselors to be themselves.

If counselors do not specialize in geek therapy or do not find that it fits well with their clinical approach, then they should refer clients to someone who does have knowledge working with this population, Davis says. If a counselor’s first reaction to somebody whose main hobby is cosplay is “What is that?” then it might not be a good match. But counselors who aren’t into fandom, Davis adds, can still put in the work and educate themselves on what fandom means to their clients.

However, in general, a client whose identity is centered on fandoms often works better with a counselor who also has a passion for them. “Can you imagine what it would be like to go to your therapist and [have] them express to you from that same place because they have that same love, same passion and you can recognize them?” Davis says. “If you don’t have knowledge of fandoms, you could seriously consider creating a referral list for people like me who will look at that and be like, ‘Cool, let’s make that happen.’”




Parasocial relationships

Parasocial relationships (i.e., a one-sided relationship between a viewer and a media figure) and fandoms are closely intertwined. Not every person involved in a fandom has a parasocial relationship, but the relationships with fictional characters or actors is often an important part of many people’s fandoms.

As with any kind of relationship, a parasocial relationship can become toxic, but they can also be beneficial. People who are isolated in their real life may find community and friendship online with their peers and with fictional characters, says Lindsay Meagher, a licensed mental health counselor at Protea Wellness in Seattle. Having parasocial relationships can be a way to make real friendships with people online and/or in person by bonding over a shared love of fandoms, they explain.

These parasocial relationships can be a way of exploring aspects of one’s identity, such as gender or sexuality, that they may not be able to do with the people in their lives. Parasocial relationships provide a sense of community and healing that the person may not otherwise have, Meagher notes.

Ashley Myhre, a licensed marriage and family therapist in Minneapolis, says that parasocial relationships can often be handled in a lot of the same ways as real-life relationships. There isn’t a different technique needed to coach somebody struggling with a parasocial relationship.

Myhre sometimes incorporates the parasocial relationships in session. She may ask a client to imagine what the person or character they are in a parasocial relationship with would say to encourage them when they’re in a depressive state, or she may ask the client to find a positive attribute they share with this person/character. If a client’s favorite character is physically fit, for example, then that client may be more inspired to make healthier lifestyle changes because they want to emulate the character or because seeing this character’s lifestyle motivated them to make changes they were already wanting to make in their lives. In addition, seeing a fictional character go to counseling or talk about their mental health can help destigmatize the idea for potential clients.

But at the end of the day, parasocial relationships with fictional entities often come down to people seeing similarities in experiences that are like their own. Someone who is neurodivergent, for example, may not feel accepted in their real-life social circles, so having a parasocial relationship with a fictional character or celebrity who is also neurodivergent can help them figure out their own identity and accept their differences.

“I think so much of it [parasocial relationships] comes down to a feeling of being seen, a feeling of being understood, validation [and] representation,” Myhre says.



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Samantha Cooper is a staff writer for Counseling Today. Contact her at scooper@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.