Tag Archives: therapeutic alliance

Incorporating clients’ faith in counseling

By Lisa R. Rhodes November 2, 2022

A South Asian Muslim woman in her 20s lives at home with her Muslim family and has been struggling in her relationship with her parents. She feels they interfere with her ability to make decisions for herself and treat her like a child.

The woman decides to go to therapy. After listening to the client talk about the issue, the counselor says, “If you move out, this will no longer be an issue.” But this advice was not helpful, and this woman sought out a different clinician, which led her to Nadia A. Aziz, a licensed professional counselor (LPC) at the Empowerment Therapy Center in Manassas, Virginia.

“The client felt the counselor wasn’t informed on how to deal with issues in a culturally informed manner,” Aziz recalls. “The counselor failed the client by not incorporating [her] values” into treatment.

In South Asian cultures, which embrace the spiritual teachings of Islam, Hinduism, Sikhism and Buddhism, it is expected that adults live at home with their families until they either get married or move away for work or college, explains Aziz, who is South Asian and Muslim.

“A counselor suggesting moving out of a family’s home would be insensitive to the [client’s] cultural and religious needs because the client was not able to move out and it wasn’t a realistic expectation,” she says.

Aziz, a member of the American Counseling Association, worked with the young woman in therapy to set healthy boundaries and develop assertive communication skills so she could express her feelings and needs to her parents in a way that was respectful of her family’s cultural and religious beliefs.

An evolving practice

This scenario is an example of what many clinicians fear — not knowing how to respond to the religious and spiritual needs of a client. J. Scott Young, a licensed clinical mental health counselor and professor in the Department of Counseling and Educational Development at the University of North Carolina at Greensboro, says his research on religion and spirituality in counseling, which includes conducting counselor surveys, shows that many mental health professionals feel anxious and uncertain about incorporating a client’s faith into therapy.

“They don’t want to do anything unethical,” Young explains. “They’re worried that they don’t know what to do to help people with [these] issues.”

The uneasiness counselors feel stems from a long history of prohibiting the intersection of religion and spirituality in the therapeutic process. In the third edition of Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice (published by ACA), Young and Craig S. Cashwell point out that “religion has long been a highly controversial topic in the mental health disciplines.” They also note that Sigmund Freud and B.F. Skinner, two pioneers of psychology, considered religious and spiritual belief systems to be frivolous.

However, the counselors interviewed for this article all agree the counseling profession, and the mental health field in general, has evolved over the years to regard religion and spirituality as important additions to counseling education and practice. And they stress that with the proper education, training, and focused introspection into their own religious and spiritual beliefs, counselors can effectively bring a client’s faith into the therapeutic process, if that is the client’s desire for treatment.

In 2009, the Association for Spiritual, Ethical and Religious Values in Counseling (ASERVIC), a division of ACA, developed the Competencies for Addressing Spiritual and Religious Issues in Counseling to serve as a guideline for counselors seeking to incorporate a client’s religion and spirituality into practice. The competencies work in tandem with the ACA Code of Ethics.

Jesse Fox, an ACA member and the current president of ASERVIC, says evidence-based research into the importance and efficacy of religion and spirituality have made them topics for therapeutic exploration.

“The evidence base for interrelationships between spirituality, religion and mental health has grown exponentially,” says Fox, an associate professor of counselor education at Stetson University. “In the most recent systematic review in 2012 produced by Harold Koenig at Duke University Medical School, there were over 3,000 published peer-reviewed studies documenting the connection between spirituality, religion and health. In fact, the number of studies grows exponentially every year.”

This empirical work has mapped out how these domains — religion, spirituality and health — of human experience function psychologically, he explains.

“The net effect is that mainstream mental health models have recognized that spirituality needs to be considered alongside of other dimensions of wellness like emotional health or physical health, as well as intersectional models of identity like race and sexuality,” Fox says.

Religion and spirituality continue to be important to many in the United States. According to a 2022 Gallup Poll, 81% of U.S. adults believe in God. Statistics such as this, Fox says, suggest that religion or spiritual matters will likely be “an aspect of a client’s identity” in counseling.

Young, an ACA member, says research has shown that people who have a faith or religious commitment that supports them tend to experience less anxiety and depression, more stability in their primary relationship, and more stability and commitment in their work and career. This commitment “seems to be sort of a buffer against some of the stressors that they might otherwise face,” he explains. “And if that’s that case, [it] sort of helps to support their mental health as well.”

People often use spirituality or religion to make meaning of their lives, notes Young, who treats clients at Triad Counseling and Clinical Services PLLC, which has offices in High Point and Greensboro, North Carolina. “In counseling, we talk to people about their childhood, their parents, their family drama … [and] their sex life — all these are very personal things for people,” he says. “At times counselors are hesitant to discuss spirituality or religion for fear that it is too personal or that they may misstep.”

Know thyself, know the client

The counselors interviewed for this article say that before attempting to bring a client’s faith into therapy, counselors should thoroughly explore their own religious and spiritual beliefs, or the lack thereof.

“If counselors have not taken the time, or realized the importance of taking the time, to know themselves — their values, their beliefs, their own spirituality and religious preferences — then that’s not going to be a good match for clients who have needs in that area,” says Amy Evans, a licensed professional clinical counselor in Minnesota.

“The challenge is making sure we do not push our own values, worldview and perspectives on our client,” Evans stresses, which is something both the ACA Code of Ethics and ASERVIC competencies make clear counselors should not do. “To make sure we’re not doing that, we have to know ourselves,” she adds.

Aziz says she was able to explore her religious and spiritual identity in undergraduate and graduate school, where she took courses in multicultural counseling and faith-based counseling, as well as other classes that encouraged self-discovery, self-awareness, and exploring one’s own values and biases in the realm of religion and spirituality.

Justin K. Hughes, a LPC in Dallas who offers religious/spiritual integration, most commonly for Christians, says he learned important tools for bringing a client’s faith into treatment from his own experience receiving counseling as an undergraduate student and from the counselors he worked with during his Christian seminary training and clinical internship.

Hughes, owner of Dallas Counseling PLLC, says these mental health professionals set the model for him by being respectful and humble and always asking questions to assess his needs and learn more about his religious and spiritual experiences. He says he now mirrors these traits in his own practice.

Faith and self-disclosure

While it is important for counselors to feel comfortable with their own faith and belief systems, the counselors interviewed for this article agree that it is not necessary for clinicians to share this part of their lives with clients. If clients do inquire about their faith, they advise clinicians to be thoughtful in how they respond.

Young, a past president of ASERVIC, says he doesn’t discuss his spiritual views in session unless the client brings up the topic, and even then, he is careful not to divulge too many details.

“I have, on occasion, had a client who really wanted to know how I see these things, so I always preference [my response] with ‘We’re here for you,’” Young explains, noting that he will then try to explore what salience religion and spirituality holds for the client and what the client may be trying to learn by asking about his beliefs.

Lemonsoup14/Shutterstock.com

“I do not try to deflect or redirect if they are truly curious,” Young says, “but I do want to understand why it is important for them to know my beliefs.”

Aziz says her faith is evident in the photograph she posts on Psychology Today’s directory of mental health providers and her practice’s website. “I wear the head scarf, the hijab, [so] it’s kind of hard to miss,” she says. “A lot of times I do get contacted through those avenues, so I am implicitly disclosing that I am Muslim, and they are looking for a Muslim therapist.”

If clients inquire to know the specifics about her faith, Aziz says she always brings the discussion back to what the client is looking for and what they need in treatment. Although a discussion of Aziz’s faith may sometimes be helpful in building rapport with a client, she is mindful that it is not relevant to the therapeutic process.

“A lot of times it is [about] setting boundaries with them,” she says, “and making sure they understand that the counseling session is not about me, it’s about [them], keeping the focus on them.”

Hughes, who specializes in treating obsessive-compulsive disorder (OCD), anxiety and related disorders, is a member of the International OCD Foundation, which has been examining the role of religion and spirituality in the treatment of OCD during the past couple of years.

Hughes says he is “usually fairly open about being a Christian” with clients if they bring it up. For example, some of his clients have asked, “Are you a Christian?” “Would you be willing to pray with me?” and “I’m not very religious. Are you OK with that?” He only provides specific information if he feels it will be a therapeutic benefit for the client, which he notes varies case by case.

Counselors do not have to share the same religious or spiritual beliefs as their clients to be effective in therapy, yet for some clients, having a match in faith may matter to the client. Evans, an associate professor and program director of the master’s in counseling program at Bethel University in St. Paul, Minnesota, says research shows that what matters in practice is the quality of the therapeutic relationship and the counselor’s responsiveness to the client.

“If a counselor is trained well and really considers the client’s worldview, culture and values — then that can be helpful to the [therapeutic] relationship,” says Evans, an ACA member. A counselor’s training and ability to modify therapeutic techniques to meet the client’s needs is what is most helpful in practice, she stresses, not the counselor’s faith.

Young acknowledges that a counselor’s faith may be important for some clients. If there’s not a match in faith, it may be barrier for some clients who may not feel as safe in the relationship as they should, he explains. But “as long as the counselor is open and meeting the client where they are [and] they’re not anti-religious or struggle with it themselves,” Young says, “it really shouldn’t make much of a difference.”

Broaching the topic

Counselors must first determine a client’s therapeutic needs to find out if they would like to include their faith in counseling. The counselors interviewed for this article suggest bringing up the topic of religion and spirituality in the first session and including it on intake forms.

“One of the most important things is to … broach the topic,” Evans says. “If we don’t let clients know it’s OK to talk about it [religion and spirituality], they may not know it is acceptable to bring it up.”

Evans says counselors should also inquire about a client’s faith on the intake form. Then during the first session, they can ask open-ended questions in response to what clients have shared on the form. Evans provides a few examples of things counselors can say to initiate this conversation:

It sounds like your spirituality/religion is important to you.
How might you envision bringing your spirituality/religion into the therapeutic work we are doing?
You mentioned that spirituality/religion is an important part of your life. How might it relate to the therapeutic goals we have agreed to focus on?

Evans says partnering with the client to agree on goals, including goals surrounding the client’s faith, helps builds the therapeutic relationship so it can be effective and have positive outcomes for the client.

Aziz also brings up the client’s faith during the intake process. “I ask [clients] if there is anything they want me to know about their cultural or religious beliefs and if they are looking for faith-based counseling,” she says.

Aziz notes that about 70% of her clients are South Asian and follow the teachings of Islam, Hinduism, Sikhism or Buddhism, and about 30% are from a different cultural background or faith. So she first works with clients to help them identify their own values. “That gives me a better understanding of what they’re looking for in session, and I tend to take the counseling sessions in those directions,” she says.

Blending faith and counseling

Once counselors assess the religious or spiritual needs of the client, or the lack thereof, they can work with the client in treatment to resolve any issues or explore new insights. Young says bringing a client’s religion or spirituality into practice should be a collaborative process that is not one size fits all.

One approach, he continues, is to ask open-ended questions that explore the client’s thoughts and feelings around their religious or spiritual practices and traditions. For example, he says counselors could ask:

When or where do you feel most connected to the larger whole?
What brings you the greatest sense of peace in your life?
What rituals, if any, do you practice that bring you comfort (prayer, meditation, walks in nature, etc.)?
Have you thought about using these rituals or practices to help resolve problems?
Do you have an understanding about a higher power? How is this helpful to you?

Evans co-authored, along with Jennifer Koenig Nelson, an article exploring adapting counseling to clients’ spirituality and religion, which was published in Religions in 2021. In it, Evans and Nelson argue that using the therapeutic approach of cultural humility to incorporate a client’s religion or spirituality into practice can result in positive outcomes for the therapeutic relationship and the client’s treatment goals. Citing Joshua Hook and colleagues’ 2013 article published in the Journal of Counseling Psychology, they define cultural humility as “having an interpersonal stance that is other-oriented in relation to another individual’s cultural background and experience, marked by respect for and lack of superiority toward another individual’s cultural background and experience.”

Cultural humility “relates to positive outcomes and reduces power dynamics in the [therapeutic] relationship,” Evans says. “The openness allows the counselor to step back and have the client determine what is most salient to them, rather than the counselor pushing for the client to focus on certain parts of their identity.”

The counselor operating from a stance of cultural humility “allows for the client to determine if spirituality/religion is something important to them [or] salient to the work they are doing in counseling,” Evans continues. The client can then decide if they want their faith brought into counseling.

In their article, Evans and Nelson suggested an adaptation to Hook and colleagues’ guidelines for integrating cultural humility into therapy that focuses on religion and spirituality. Their revised guidelines are:

Remain humble when engaging with clients around spirituality and religion.
Do not assume you understand the client’s spirituality and religion based on prior training, knowledge or experiences.
Explore spirituality and religion with the client to determine what is positive and what might be detrimental in relation to their beliefs.
Remain curious about the spirituality and religion of the client as it relates to the presenting issues and ask questions when appropriate.

Aziz finds creative ways to incorporate the client’s faith into session when appropriate. If a client is having a hard time controlling their anger, for example, she may integrate the client’s religion into a breathing and mindfulness exercise to help them learn to respond to stressful situations in a healthy way.

In this scenario, Aziz would first ask the client to come up with a word or phrase that is connected to their faith and has a calming effect. The client must be able to repeat the word or phrase with ease. A client may choose the word “patience” as their mantra for breath exercises, for example, because it reminds them of the Islamic scripture “God is with those who are patient,” Aziz says.

She would ask the client to relax and clear their mind of any thoughts. Once the client is settled, she would ask them to take four deep breaths in through the nose, hold for a count of six and then breathe out through the mouth for a count of six. While engaging in this breathing exercise, they would focus on repeating their mantra in their mind. This exercise is a helpful way for clients to calm their body and mind and focus on inner peace, Aziz notes.

Asking clients to select a mantra that resonates with them makes it more likely that they will follow through with the practice on their own, Aziz says, because it helps to make the practice personal to them. And that approach works with clients whether they are religious or nonreligious, she adds.

“If the client requested faith-based counseling, they usually gravitate toward phrases that have religious significance” to them, she says, noting that she may also talk to the client about why the phrase is important to them.

The guided imagery “wise being” exercise (see lifepluswork.com/guided-imagery-wise-being) is another technique that counselors can adapt to incorporate a client’s religion/spirituality, Aziz says. This technique, she explains, allows clients to tap into their own faith and values.

Aziz begins the exercise by asking the client to imagine a safe space where they would feel comfortable having a personal conversation with someone they view as a wise being. The purpose of the conversation is to allow the client to discuss their problem or issue with the wise being without judgment and to receive guidance from the wise being on how to resolve or approach the problem, Aziz says.

“A lot of times people might pick a spiritual guide based on their faith,” Aziz says. For example, a Muslim client may select the Prophet Muhammad, a Christian client may select Jesus Christ or a Buddhist client may select Buddha.

After the client selects their wise being, Aziz asks them to imagine the guide walking toward them to begin the conversation. “It is almost a spiritual moment for them to have this conversation,” she notes. They “may have felt the presence of their spirit guide” during this exercise. And the exercise often provides clients with clarity or helps lead them to what they want to discuss in counseling, she adds.

Aziz leaves the decision to share the details of this conversation with her up to client. Sometimes, it takes clients a few sessions before they are ready to share what they felt or experienced in that moment, she says.

If a client chooses to discuss the exercise with her, Aziz often asks, “Why do you think [the] wise being said what they said?” Then together they process the client’s feelings about the wise being’s message and its meaning. She asks, “How are you going to incorporate [the wise being’s advice] into your life?”

Overcoming challenges

Integrating a client’s faith into session may not be easy for some clinicians. Young reminds counselors that they don’t have to be an expert on a client’s religious or spiritual beliefs to be effective.

“Counselors don’t have to have the answers for [a] client’s faith questions,” he says. “It is an important part of faith development for people to struggle with questions that do not have clear answers.”

Young advises counselors to remember that staying present for the client, being curious about their experience and not projecting their own values onto the client can help to navigate the ups and downs of practice if they are focusing on a client’s faith or another area of the client’s life.

Hughes says counselors must be willing to meet challenges and make reasonable mistakes when bringing a client’s faith into practice, and they must be willing to use compassion to correct themselves. But when counselors deal with religious and spiritual sensitivities, they don’t feel they have any space for errors.

Counselors don’t want to violate the code of ethics, Hughes says, but even if they’re doing therapy competently, they may sometimes ask irrelevant questions or make a human gaff. For example, he once worked with a Jewish client who often brought details about her faith into therapy. But when he attempted to define the Hebrew word “shalom” in reference to the client’s therapeutic goals, the attempt “fell flat,” he recalls.

“I have studied some of the original Hebrew and knew what I was talking about technically,” Hughes explains. But the client “corrected me from her personal understanding, and because I am neither Jewish nor living her life, she had the right to define what the word meant to her in relation to her goals.” This exchange highlights the need for communication and questions as well as the importance of never taking things for granted, he adds.

Fox, executive director of the Episcopal Counseling Center in DeLand, Florida, says navigating a client’s faith can be challenging for counselors when they realize the diversity of religious and spiritual perspectives.

“You encounter a myriad of worldviews, practices, frameworks of meaning, [and] it can be daunting about where to start,” Fox says. It can be hard for counselors to “discern when a client’s religious or spiritual life has become unhealthy,” or if the real dangers of imposing their values onto the client have become evident, he adds.

Fox and Aziz recommend counselors find a mentor or supervisor or seek additional training if they have questions or want guidance on discussing faith with clients. “I think there’s a lot of benefit to talking to colleagues and supervisors [to get] a different opinion or view of things,” Aziz says.

Be curious

The counselors interviewed for the article agree that clinicians should take advantage of opportunities through professional channels and in their community to learn more about the diversity of religious and spiritual traditions of their clients.

“We learn best by engaging with individuals who are different from us,” Evans says. “Get out there, get to know people, … and be curious.”

She suggests attending different religious services and reaching out to local religious leaders who are open to sharing information about specific religious and spiritual practices.

“[Do] what makes sense clinically,” Evans says. “Start exploring things. … Take the time to be curious and investigate and interact with people outside [your] regular circle.”

Most professional trainings about religion and spirituality are Christian in nature, Aziz notes, so counselors who are seeking guidance about other religious or spiritual traditions should consider reading books or researching multicultural blogs.

Evans, Fox and Young recommend counselors take advantage of the resources offered by ASERVIC, including Counseling and Values (their official publication and one of the oldest peer-reviewed journals on the topic of spirituality and religion), their annual conference and webinars.

Fox serves as co-investigator of the Spiritual and Religious Competency Project (srcproject.org), an initiative funded by the John Templeton Foundation, which aims to provide mental health professionals with basic competencies to address the spiritual and religious aspects of their clients’ lives. His team of researchers are “testing methods of training mental health professionals in spiritual and religious competence” and are tracking how mental health professionals may utilize this training nationwide. They are also “using implementation science to discover the best ways to make this type of training more likely to happen in mental health care in the future,” he says.

The project’s early research has found that more mental health training programs are open to including religious and spiritual studies, but staff lack the training to confidently teach and supervise students, Fox explains.

“Over the next five to 10 years, we are hoping that through our efforts we see this gap close so that every client who brings religion and spirituality into their counselor’s office will be met with competent help,” he says.

Young is also hopeful about what the future holds for the integration of religion and spirituality within counseling. He says the more research that is done in this area and the more conversations that takes place among counselors, the more possibilities there are to expand the reach of religion and spirituality in clinical practice for the benefit of clients.

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

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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.

Confidentiality comes first: Navigating parent involvement with minor clients

By Bethany Bray October 28, 2022

What is said between a counselor and an individual client is confidential, even when the client is a minor. But parents often want to be kept in the loop about their child’s progress in therapy. This can put the counselor in a tricky situation, especially when the parents want to control or influence the counseling process.

The only scenario in which counselor-client confidentiality can be broken is in situations that necessitate protecting the client or others “from serious and foreseeable harm,” such as suicidal intent. (For more on this, see Standard B.2.a. of the 2014 ACA Code of Ethics.)

Marcy Adams Sznewajs, a licensed professional counselor (LPC) who often works with teenage and young adult clients at her group therapy practice in Beverly Hills, Michigan, says she empathizes with parents who ask about what she’s covering in counseling sessions with their child. However, she finds it helpful — and necessary — to offer a firm explanation of counselor-client confidentiality whenever she begins counseling a young client.

Sznewajs says that she emphasizes to parents that she will let them know if their child discloses anything that will put the child in danger. She also makes it clear to both parties that she will only invite parents into the counseling sessions if the young client grants permission.

This conversation is often not what the parents want to hear, Sznewajs admits, but it is important because it spells out the boundaries of what the counselor is obligated to tell the parents and reassures the client that their privacy will be respected.

Sznewajs stresses to families that they all must trust the process for her work to be effective.

“It’s important for the teenager to trust an adult with these difficult thoughts and feelings, and legally and ethically I have to keep it confidential,” says Sznewajs. “I’d be doing my client a huge disservice [if I disclosed session details to the parents]. That’s not only unethical, it’s damaging — and what does it teach the kid? That this person that you’re supposed to trust, you can’t.”

The feelings behind the questions

Parents’ concerns and questions about the work their child is doing in therapy are often rooted in fear, says Martina Moore, a licensed professional clinical counselor supervisor with a mediation and counseling practice in Euclid, Ohio. Not only do parents worry that the challenging behaviors that caused their child to seek counseling, such as rule breaking, isolation, defiance or problems at school, will have negative long-term outcomes in the child’s life, but they might also feel these issues are a reflection of their parenting abilities.

“Parents sometimes have such anxiety about their children it’s [gotten] to the point where they are increasing their child’s anxiety,” notes Moore, president of the International Association of Marriage and Family Counselors, a division of the American Counseling Association.

Although Moore makes a point to validate these fears with parents, she also emphasizes that it’s good for the child to grow and build autonomy through counseling on their own. She applauds parents for seeking help while explaining that she needs the freedom to work with the child alone for the counseling process to work.

“I also spend time with parents to dig into what their fear is. They’ve come to counseling [with their child], so they must believe that there is benefit in this process,” Moore says. She emphasizes to parents that they need to trust the process. “I spend a lot of time with parents getting their buy-in,” she notes.

In addition to fear, parents may also struggle with strong feelings of shame for having a child who is engaging in risky behavior and failing to thrive.

Le’Ann Solmonson, an LPC in Texas who has extensive experience working with children and adolescents, says she makes a point to acknowledge and normalize parents’ feelings of vulnerability and worry. If appropriate, Solmonson says she will sometimes disclose that she’s experienced similar feelings when her adult children sought therapy.

“No parent is perfect, and you worry over feeling like they are talking [in therapy] about what you’ve done wrong,” says Solmonson, the immediate past president of the Association for Child and Adolescent Counseling, a division of ACA. “It’s a very vulnerable thing to have your child go to counseling. You can’t help but feel that it’s a reflection on you as a parent and feeds into fears that you’re ‘screwing your kids up.’”

Navigating the balance

Counselors often need to get creative and act diplomatically to keep parents in the loop while maintaining young clients’ confidentiality and trust.

When parents insist on being involved in their child’s counseling, Moore negotiates with both the parents and client to find a plan that they all agree on while staying within ethical boundaries.

This was the case for a teenage client Moore once counseled who had substance use disorder. The parents were worried about their child and wanted to be involved in the counseling process. Moore facilitated a discussion and, eventually, they all came to an agreement that Moore would work with the teen alone but would let the parents know whenever the client had a relapse or break in recovery, she says.

Keeping lines of communication open and having regular check-ins with parents is beneficial to the counseling process with young clients, Solmonson notes. She often prompts child or adolescent clients to identify one small thing they are comfortable sharing with their parents at the conclusion of each counseling session, such a breathing technique they learned or new words they discovered to describe their emotions. This keeps the parents in the loop while ensuring that the client maintains control over the process.

When parents are left completely in the dark about their child’s work in counseling, it can exacerbate worry, cause them to “fear the worst” and catastrophize about what the child might be saying, Solmonson adds.

Sznewajs notes that talking with young clients about keeping their parents updated also provides the opportunity to check in with the client and ask what they feel is going well. She sometimes begins by asking the client how they feel things are going in counseling and transitions to what (or if) they would want her to share with their parents about their progress.

Disclosure of life-threatening behavior

When a young client is engaging in risk-taking behaviors that are life threatening (i.e., suicidal actions, self-harm), ethically, parents need to be brought into the conversation, says Hayle Fisher, a licensed professional clinical counselor and director of adolescent services at a behavioral mental health provider in Mentor, Ohio. While this is crucial to do, it can also impair the therapeutic relationship with the teen, she adds.

Fisher finds the vignettes in the 2016 British Journal of Psychiatry article “‘Shhh! Please don’t tell…’ Confidentiality in child and adolescent mental health” particularly helpful for examples on navigating these conversations. She keeps the following notes for herself, drawn from that article, for situations when she must disclose a young client’s harmful behavior:

Tell the client what you (the counselor) are planning on disclosing to the parents, with an emphasis on the full context of why you need to. Ask for their feedback on how they might like to edit what you plan to say.
Talk through the potential benefits and costs of disclosing to the parents. Ask the client how they feel about the disclosure and consider their views as you move forward.
Validate any fears the client may have about the disclosure, such as losing access to resources and freedoms, feeling blamed or ashamed, or being concerned that the police or social services will become involved.

To maintain trust and a therapeutic alliance with young clients, Fisher emphasizes that it’s important for a counselor to give the client as much control as possible over how this communication will occur. If the disclosure happens during an in-person session and the parents are nearby, she gives the client the choice to either stay in the room or step out and wait in the lobby when she invites the parent(s) in to tell them.

Fisher also gives young clients the option to tell their parents before she does. However, this is only appropriate if the client’s risk of harm is not imminent, Fisher stresses. In this scenario, she tells the client that she will call at a certain time the following day to speak with their parents, check in and provide support for the parents and client.

“This option is especially powerful,” Fisher explains, because it “reinforces the adolescent taking accountability for their actions, increases communication skills and fosters independence in the situation so they are not dependent on the counselor for navigating conflicts with their parents.”

Sznewajs also takes a collaborative approach when it’s necessary to break confidentiality to inform a client’s parent or guardian about harmful behavior or intent. She says she tries to take the client’s feelings into consideration while modeling firm boundaries.

Although not having the conversation with the parents isn’t an option, client can choose how and when it happens, Sznewajs explains. She offers to involve the parents in person, call them on the phone, do a video chat during the counseling session or wait until after the session ends.

Sznewajs says she explains to young clients: “I want to make sure you stay safe, so we have to bring your parents into this conversation.” She adds that she tries to “do it in a collaborative way, even when it [the situation] is dire.”

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Read more on this topic in the Ethics Update column in Counseling Today’s November print magazine, “Respecting clients’ rights when working with children.”
Also, see Counseling Today’s November cover story for an in-depth exploration of counseling for parent-teen conflict.

SeventyFour/Shutterstock.com

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

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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 a clinical selfie

By Bethany Bray October 25, 2022

“But first, let me take a selfie.”

This phrase, which was first popularized in The Chainsmokers’ 2014 breakout hit song “#Selfie,” has become a common saying in today’s culture — and one that is sometimes used to satirize younger generations who can’t seem to experience something without documenting it with a self-portrait.

On the surface, the act of taking a selfie can seem shallow or self-promotional. But Amanda Winburn and Amy King, both counselor educators who have a background as a school counselor, say that when used intentionally and in a structured way, selfies can become a therapeutic tool and a way to spark self-reflection, engagement and connection with younger clients.

“We know that children are engaged in” taking selfies, says Winburn, a licensed school counselor, licensed professional counselor and registered play therapist. “So why not take the positive attributes of this practice and expand upon it” in counseling?

Selfies in session

Winburn and King, who have presented on the therapeutic power of selfies at conferences of the American Counseling Association and the American School Counselor Association, have used selfie activities as a therapeutic intervention in individual and group counseling settings.

“This is just one more way we could give children and adolescents an opportunity to express themselves and narrate their story,” says Winburn, an associate professor of counselor education at the University of Mississippi. “We try and incorporate [clients’] worlds in our work, and selfies are an everyday part of our world and everyday part of expression for children, adolescents and adults. It really is the new self-portrait.”

However, Winburn and King stress two important caveats to this work:

Practitioners should take care to ensure that any selfies captured in sessions are not taken with a device that is connected to the internet (i.e., not the client’s personal cellphone) so the images cannot be shared or used in a nontherapeutic context.
Practitioners must obtain consent from a parent or guardian to capture the image of any client under the age of 18.

King, a certified school counselor and provisionally licensed professional counselor in private practice in Mississippi, uses a tablet computer that does not have internet access to allow students and clients to take selfies. She prints the selfie images and keeps them in a client’s file to refer to during sessions and deletes the images from the device. The tablet and client files are kept in a locked cabinet in her office when not in use, she explains.

Tapping into self-expression and boosting empathy

Having young clients take selfies during counseling sessions can serve as a visual and relatable way for them to track their progress in therapy, Winburn and King suggest.

Selfies can document physical aspects of improvement and growth in ways that a client may not notice without a visual record, such as smiling or holding their head up more, sitting tall and appearing more confident, Winburn explains.

When she was a school counselor, King once used selfies to help a student who was struggling with self-confidence. The student kept the printed selfies that she took in counseling sessions in a journal, to which she added notes and drawings. When King and the client talked about her therapeutic progress and looked through the selfies together, the young client was able to recognize that she looked happier and more confident in her progression of photos throughout the year.

She was able to note that she had gotten taller and that her smile was brighter. “She was glowing because she was looking at herself in a really positive way and reflecting about that,” King recalls.

King, a lecturer in counselor education and supervision at Boise State University, finds that students love to look back at their progress in counseling, and by using selfies, young clients can visualize that progression of moving away from having a tough time to having a better outlook on their situation or life.

In addition to strengthening expression and self-confidence, using selfies in this way also provides an opportunity for counselors to explore and process clients’ feelings of self-doubt or self-criticism, Winburn says. In therapy, selfies can be a visual portrait of a client’s narrative and a discussion starter for work that increases self-awareness and emotion recognition.

Winburn advises counselors to ask clients questions to understand the motivations behind their self-expressions and explore if they are trying to portray themselves differently than they really are. For example, she says clinicians can ask, “How does seeing that image make you feel?” or “What makes you feel that way?”

Winburn asks her counseling students at the University of Mississippi to take a selfie at the beginning and end of their day for an entire week. She tells her students, “It’s a way to step out of your comfort zone and process how you were feeling [that week] and how you portray yourself.” Then they reflect together in class on the story their selfies tell, which can be quite eye-opening, Winburn says.

King also used selfies in group counseling with second grade girls during her time as a school counselor. The group’s focus was on building confidence, communication, friend making and social skills. Learning to give and receive positive affirmations — to oneself and others — was an important component of this group work, King notes.

King, assisted by graduate counseling interns, had each group participant take a selfie with a school-issued tablet computer. The student would first look at the selfie themselves and then share it with the group. This activity allowed participants to open up and talk about the feelings their selfie elicited and, in turn, prompt group members to offer positive feedback.

It was a powerful experience that boosted the second graders’ empathy, reflection and listening skills and their ability to consider others’ perspectives, King says. The students would listen, connect and make comments such as “your eyes are really sparkling in that one,” she recalls.

After the group had been meeting for a little while, teachers and recess monitors at King’s school began to report that the students who were in her counseling group started to have more positive interactions during recess, she says.

Using selfies in counseling can help children actively learn and foster positive feelings about themselves as well as learn about individual and cultural differences in group settings, King notes.

“There’s no right or wrong way to make a selfie,” she adds.

Keeping an open mind

King and Winburn acknowledge that counselors can sometimes be skeptical of using technology in sessions, especially mediums such as selfies that can have negative connotations. However, they feel that when used in an ethical and appropriate way, selfies can strengthen trust and the therapeutic alliance with young clients.

It can also be a way to model that technology can be used in a positive way, to build each other up, King adds.

“Make sure you’re using safeguards to keeps clients safe, but try it [using selfies], embrace it and be open to it,” Winburn urges. “Especially with adolescents, counselors need to be playfully engaged and aware of where they are. This is an active way of embracing the world that they live in and meeting them where they are.”

wavebreakmedia/Shutterstock.com

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Related reading, from Counseling Today:

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

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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.

Breaking the silence around the childhood sexual abuse of Black men

By Lisa R. Rhodes August 30, 2022

In October 2019, Tyler Perry, the multimillionaire writer, actor, and movie and television producer, shared painful details from his childhood in an interview with People magazine. “I don’t think I ever felt safe or protected as a child,” Perry recounted, as he explained how his father, who he later learned was not his biological father, routinely beat him with a vacuum cord.

In addition to the physical abuse, Perry disclosed that by the time he was 10 years old, he had been sexually abused by three different men and a woman — all of whom were known by his family.

“It was rape,” Perry said in the interview. “I didn’t know what was going on or the far-reaching effects of it.”

Perry is not the only Black male public figure to reveal that he was sexually abused as a child. Other Black male public figures, such as gospel singer Donnie McClurkin, have come forward to reveal the harmful impact of this early trauma. Despite these public disclosures, the silence that surrounds the childhood sexual abuse of Black men is deafening.

“In many homes and social circles, the topic is still avoided — it’s taboo,” says Robin D. Stone, a licensed mental health counselor in New York City and a survivor of childhood sexual abuse. “In some cases, men haven’t shared with anyone that they’ve had this experience, that they have this history.”

The fact that it is taboo means that Black boys who have been sexually abused rarely, if ever, tell anyone that they have been violated and the silence continues into adulthood. Stone, a member of the American Counseling Association, says the impact of childhood sexual abuse on Black men leaves them with psychological wounds that they learn to “pack away” for years.

The silence surrounding this issue makes it difficult to know how pervasive it is. According to a 2006 study by the Centers for Disease Control and Prevention, about 1 in 6 boys in the United States were sexually abused before age 18. And the Children’s Assessment Center acknowledges that race and ethnicity are key factors, with Black children being almost twice more likely to experience child sexual abuse than white children.

Rebekah Montgomery, a licensed professional counselor and owner of Dove’s Heart Counseling LLC, a practice with offices in Ann Arbor, Michigan, and Detroit, agrees that sexual assault and any form of sexual abuse are rarely discussed in the Black community.

“You can learn proper coping skills, you can reframe your brain, but it is still going to be something that can trigger later in life,” says Montgomery, an ACA member who counsels Black male survivors of childhood sexual abuse. “When you awaken those sexual feelings as a child, especially before puberty, you develop unhealthy ideas about what sex is and what’s appropriate and not appropriate.”

Building trust and safety

The counselors interviewed for this article all agree that to build rapport with Black male clients, counselors must be willing to engage in direct, honest and open communication, which creates an environment where the men feel safe enough to trust the therapeutic process.

“I feel when they come [to counseling], they want to say something [about the sexual abuse], but you have to build their trust because they live in a country where — because of the color of their skin — they don’t trust because things have worked against them in very purposeful ways,” says Damion Davis, a licensed professional counselor in Addison, Texas.

“In some cases, African American men don’t trust counselors who are of a different race than they are because they assume that there won’t be a cultural understanding,” he adds. “If there’s not a cultural understanding, then they don’t feel comfortable disclosing things.”

Davis focuses on creating a strong relationship with his clients. During the first session, he works to establish trust with his clients by asking them about their family connections, where they went to school or college, and where they grew up. He also allows clients to ask him questions, such as about his credentials and educational background. And he keeps a photo of his wife and daughter in his office to remind clients that he is human.

“It’s about mutual transparency,” says Davis, an ACA member and founder of the Davis Counseling Center PLLC.

Montgomery says a personal connection is also important in her efforts to build rapport with clients. She discusses the ethics of counseling, confidentiality and her responsibility to ensure a client’s physical and emotional safety with every client who comes into her office. She also lets clients know that during therapy they can express whatever thoughts or feelings they may have.

“My office is a judgment-free zone. All thoughts and emotions are welcome,” Montgomery says. “I like the office to feel comfortable enough for you [the client] to feel the way you need to feel, at least for that hour.”

Montgomery says she is also open to clients asking questions about her credentials and counseling experience. “They want to know they’re in good hands,” she says. “They need to get to know me just as well as I need to get to know them.”

Counselors should also acknowledge if there’s a gender or racial/ethnic difference between the counselor and client, advises Stone, owner and founder of Muse and Grace Mental Health Counseling Services in New York City. Acknowledging any differences upfront can help create a safe space for male clients to share their experience or to ask the counselor questions, she explains.

“If there’s an elephant in the room, talk about it,” she says. “It’s there whether you name it or not.”

Montgomery recommends counselors “take on the role of an expert learner” when providing treatment for clients of diverse backgrounds. “You have to be aware enough to listen and learn and apply your therapeutic techniques on a case-by-case basis,” she says. “It has to be an equal exchange of awareness, growth and learning to make it comfortable and [to] help them feel comfortable in the therapeutic environment.”

Disclosing the abuse

The results of this early trauma can lead Black men to seek counseling — but for reasons other than sexual abuse. Montgomery says some of the reasons why Black men come to her practice include anger management, depression, anxiety and sexual dysfunctions. Clients may come to counseling because they were caught looking at pornography while they were at work and are in danger of losing their jobs or because they’re having intimacy problems with their wives, she adds.

Although these symptoms can often be traced to childhood sexual abuse, many men are often unaware of the origins of their problems, Montgomery notes. “During the therapeutic process, experiences with sexual assault emerge and often get identified as a feasible cause of their mental and emotional concerns,” she says.

The counselors interviewed for this article say a client’s reaction to the realization of childhood sexual abuse can result in a tacit attempt to accept the trauma, conflicted feelings about the experience, doubts about their intrinsic worth or concerns about their sexual orientation.

“Sometimes it’s a confirmation,” Montgomery says. “They’ve already been kicking around the idea. They never thought of it [the trauma] as being [sexual] abuse, but after we confirm that they were sexually abused, they say, ‘Yeah, I kind of figured it.’”

Montgomery says confirming childhood sexual abuse often starts with asking clients how the experience made them feel. “Most Black men recognize that the sexual abuse can cause conflicting feelings,” she says. “At the time of the abuse, they may have been conflicted by their physical enjoyment and the emotional toll the abuse left.”

“Most men never disclose their sexual experiences, so we explore the unspoken rule of keeping the abuse a secret,” she continues. “We explore [state] laws that define sexual abuse/assault, including the age of consent, the difference between molestation and rape, and [the] potential consequences for someone who sexually abuses children.”

Davis, a clinical assistant professor of counseling at Southern Methodist University, says he is often the first person his clients have told about their abuse. “It’s really hard [for them] to accept the fact that the abuse happened because it leads to feelings of low self-esteem, inadequacies and, of course, anger,” he notes. “They feel this way because being sexually abused for them is very emasculating. It makes them question their manhood. A lot of people, but definitely Black men, like to feel a sense of control.” But when the abuse happened, they felt they had no control over their circumstances, Davis says.

It’s OK to express emotion

Counselors may first have to help Black men understand that they are allowed to have feelings and emotions about the experience. Stone, author of No Secrets, No Lies: How Black Families Can Heal from Sexual Abuse, notes that boys, particularly Black boys, are raised to believe that expressing emotions and anything other than the binary feelings of anger/happiness or weakness/strength is not allowed.

The taboo about childhood sexual abuse is so persistent because “many boys continue to be socialized in ways that leave them little room to be vulnerable and to express vulnerability,” Stone says. “If they aren’t able to access their feelings, they struggle socially and grow up to be men who struggle socially.”

Montgomery notes that hiding or suppressing emotions has been a survival strategy for African Americans, especially boys and men. Historically, expressing feelings or emotions carries a serious threat of violence and death — from lynching to being shot or killed by the police, she says.

Montgomery learned that Black men can put up a wall of defense against feelings and emotions when conducting research for her doctoral dissertation, which explored connections between the low use of professional mental health services by Black men in the inner city and their exposure to chronic trauma.

“I was pretty shocked by the results,” she says. All 10 of the men she interviewed for the study recognized that they had experienced some form of trauma, such as police brutality, violence and the implications of racism. But they did not consider how being guarded toward others, expressing pent-up anger, being defensive or declining to address mental health issues such as depression or anxiety can be a problem, she says.

Montgomery says the men responded to the trauma by developing a “coat of protection” that served as a valuable tool for survival. And she says she sees this same “coat of protection” in Black men who have survived childhood sexual abuse. Her study reinforces the importance of helping this clientele to express and process their feelings and emotions.

When clients have a hard time expressing how they feel about the abuse or don’t know what word or words may fit what they are thinking or feeling, Montgomery asks them to do a Google search for “feeling words” on their smartphone, and then together they explore educational websites (such as psychpage.com/learning/library/assess/feelings.html) that list different feeling words, along with charts and pictures, to help them define the word or words that best describe their emotions or feelings.

Some clients have a limited vocabulary to describe their feelings, Montgomery says, and this exercise helps them overcome that by increasing their vocabulary and awareness about the complexity of emotions. For example, they learn that sadness can also be described as disappointment, and someone who is mad may be resentful. And it reminds clients that “they have emotions and feelings and its OK,” Montgomery adds.

“We spend time identifying emotions and giving them a name,” she continues, “and we try to find the word that best fills in the blank” of how they feel about a situation or experience.

After selecting a word from the list, discussing its meaning and talking about whether it matches their emotions or feelings, clients can say, “I’m feeling disrespected right now” or “I’m feeling jealous right now.” And once clients can correctly name what they are feeling and understand its meaning, they will “always know what that feeling is in every situation,” including experiences from their past, Montgomery says.

Monkey Business Images/Shutterstock.com

She also recommends using trauma-focused cognitive behavior therapy (TF-CBT) with this population. Although TF-CBT is typically used with clients who are under the age of 18, she says these techniques can also be beneficial for Black men who have experienced childhood sexual trauma because it will help them learn healthier ways to cope with the trauma. This approach allows them to process their feelings and emotions rather than avoid them, reframe thoughts and behaviors resulting from the trauma, develop new behaviors and skills that bring a more desired or healthier outcome, and create healthy relationships, she explains.

Stone says that incorporating poetry and bibliotherapy into treatment can also help survivors process emotions. She often uses James Pennebaker’s expressive writing framework with clients who have experienced trauma. “His research shows that expressive writing helps to ease psychological and physical symptoms related to trauma and other disturbing experiences,” she notes.

This framework asks “the client to write their deepest emotions and thoughts about a disturbing experience for 15 to 20 minutes a day over four days,” Stone says. “I then invite them to reflect on what they wrote (not necessarily to share it with me) and to consider how what they wrote makes them feel, where they feel it in their body and what, if any, changes they may want to make in the way they think or in the way they are living.”

To help clients connect to a fuller spectrum of feelings, Stone also has clients practice connecting their experiences to feelings and then their feelings to bodily sensations. She uses a feeling wheel, similar to the one developed by Gloria Willcox, to help clients explore what their body feels like when they experience certain emotions such as insecure, embarrassed, bored or proud. This helps the client identify feelings and “become more fluent” in expressing how they feel, Stone explains.

Davis recommends counselors normalize clients’ feelings of anger, shame, guilt or embarrassment about the abuse. Normalization, he explains, helps to break down the stigma associated with being a survivor of child sexual abuse. “It helps them to know that they were victimized, but they are not victims,” he says.

Counselors need to affirm these clients, Davis says, and let them know they can work through the trauma of the experience and deconstruct some of the negative stigma that is tied to being a Black man who was molested.

“I tell them [clients] how they feel is appropriate because someone has taken advantage of them and together, we’re going to build them up from there,” he says. “I let them know they’re not the only man who has gone through this. … I remind them that the worse part of what they’ve gone through is over. They are in recovery mode.”

Reframing the narrative

Davis uses narrative therapy to encourage clients to tell their own story about the abuse. This approach, he says, can help clients “define the trauma in their own words and control the details of it.” He says it’s not necessary for him to know the exact details of the sexual act, but it is important to hear the client’s story because survivors attach meanings to the experience and to the abuser.

“Many times, they don’t realize that the meanings they have attached are very negative and they assign it to themselves. They don’t assign it to the abuser,” he notes. So he works with clients to help them explore the meanings they have attached to the experience, and together they begin to pull away the layers so clients can see what happened to them without assigning negative thoughts and feelings to themselves.

Davis also encourages clients to “think about their thinking” and “put negative thoughts on trial.”

He once worked with a client in his 30s who was molested by another man when he was a teenager. When disclosing the abuse, the client said, “I should have known better.”

Davis helped the client put that thought on trial. They discussed how the client felt sad, embarrassed and angry at himself because he thought he should have known how to prevent the abuse. Davis then asked him, “What evidence do you have that this thought is true?”

Davis also asked the client to image a child who is the same age he was when the abuse occurred and if he would blame that child for being sexually abused by someone they trusted. The client said he wouldn’t blame that child. So Davis asked, “But you blame yourself?”

Reframing the issue in this way, Davis recalls, helped the client consider alternative truths about his own abuse and realize he was being unfair to himself in his thoughts and feelings about the abuse.

Montgomery says she tries to reframe unhealthy behaviors in her work with clients who have been sexually abused. One client, in his late 40s, came to see Montgomery because he was angry and didn’t know why he felt this way or how to process those feelings. The client did not recognize that he had been sexually abused as a child or that his feelings of anger were due to the death of his abuser, she says.

This particular case was complex, Montgomery continues, because the client grew up in an environment wherehe was exposed to women in the adult sex industry, and from the time he was a teenager, some of these women routinely had sex with him. Crime and violence were also a part of his environment, which compounded the trauma, she adds.

Montgomery learned that he had also been abused by a female family member, but he viewed all of these sexual experiences as a “rite of passage” into manhood. Montgomery says the client told her that he’d had sex with “hundreds of women,” but he did not recognize that legally he had been violated by his female sex partners.

Black men often have a hard time seeing being abused by a woman as sexual assault or rape, Montgomery explains. “If you’re sexually abused by a woman, it’s like, ‘Congratulations! Good for you,’” she says.

Hypersexual behavior can be a response to the trauma of being abused as a child and it can lead to unhealthy behaviors if not addressed, Montgomery notes. This particular client did not understand how years of indiscriminate sex with multiple partners as a youth was an unhealthy behavior that posed a danger to his well-being, she says.

Montgomery used psychoeducation with him to discuss the risks of hypersexual behavior, such as sexually transmitted infections, pregnancy, emotional baggage from multiple partners and problems with true intimacy in relationships.

Montgomery and the client also focused on harm reduction in session. She says they discussed what needs the client felt were being met when he had the desire to have sex with multiple partners and how he could meet those needs in another way. The client decided that when he felt the need for attention or to be loved, he would choose to have sex with only one or two partners rather than multiple women, go the gym or shooting range, or spend time with his children.

The goal, she says, was to redirect the client’s energy from unhealthy behaviors to more positive choices. “We tried to help him tie his emotions to his behavior,” she explains, and to change that behavior so he wouldn’t cause harm to himself or others.

Counselors may also have to help Black men who were sexually abused by a man process their feelings and emotions around their own sexual orientation. Because of negative stereotypes associated with homosexuality within the Black community, some Black men “may feel like their manhood was tainted because of what happened to them,” Davis says. Cognitive restructuring and psychoeducation about sexual orientation, he notes, can help clients articulate what their sexual desires are and learn that they, not the sexual abuse, define their sexuality.

He also tells clients, “An experience that happened to you, that was not your choice or free will, doesn’t define your sexual orientation.”

Reclaiming power

Disclosing childhood sexual abuse can also result in victim blaming or self-blame, Stone notes, and blame can even come from peers or family members. There’s often the belief that the survivor “should have done something” to prevent the sexual act or in response to the abuse, she says.

Stone advises counselors to help clients think about what it meant to be small and/or vulnerable and how much “social capital” they or the people who perpetrated the abuse had in their family or community. “I use ‘social capital’ to speak to the extent that one is known and trusted and has influence in a social dynamic, such as a family,” she explains.

Boys are most often abused by someone who has social capital in the community, such as a coach, minister or family friend, Stone says. She suggests counselors discuss how much power or social capital the client thought they had in the situation by asking them, “Who do you think would have listened to you? Who might have taken you seriously? Who do you think would have been on your side if you had told them what had happened to you?”

Counselors can also acknowledge the strength it took for the client to survive the sexual abuse and to seek counseling, she adds. “It’s a radical act of self-care” to seek professional help, Stone notes, and counselors need to say so.

Davis says the low self-esteem that clients experience can also lead to feelings of fear and anxiety. “You feel you’re always on pins and needles because you’re waiting for the next thing to happen to you,” he explains.

Davis uses imagery exercises and reframing thoughts to help men break from a victim mentality and reclaim their power. Approaching it this way allows clients to learn to “separate themselves from what happened to them,” he says. “I have them imagine who they were when the abuse happened, and I have them imagine who they are now, standing by that person.”

He also helps clients understand that because they were children when the abuse occurred, they couldn’t protect themselves. He then asks clients, “What are you and I going to do now to protect that 12-year-old you?” This question, Davis says, can lead to a discussion on ways the client can create healthy boundaries and a sense of safety so they aren’t afraid they will fall victim to sexual abuse again or be taken advantage of by others.

“Many times, when a person experiences trauma, they get stuck there,” Davis says. “But I help them by reframing their thoughts and [bringing them] to the present day.”

Reaching out to black men

The counselors interviewed for this article all agree that the profession can do more to encourage Black men to come forward and seek mental health treatment. Montgomery suggests that counselors of diverse backgrounds and specialties advertise the fact that they treat people from marginalized groups and that they specifically treat men who have survived childhood sexual abuse.

The Black men she interviewed for her doctoral study suggested some possible ways to improve the Black community’s access to mental health support services that she says can also apply to outreach efforts concerning sexual abuse for all Black men, particularly boys. These solutions include promoting the idea of positive mental health services in elementary schools; normalizing discussions about mental health, sexual abuse and other traumas; providing interventions for coping with and calming emotions early in life; and encouraging and normalizing help-seeking behaviors.

Counselors need to be “in places where Black men are,” Davis stresses. He plays in a basketball league with other Black men, and because many of them know that he is a counselor, they sometimes ask questions about mental health issues. When they do, he connects them with other mental health professionals who can help them. Davis also suggests clinicians reach out to universities and colleges, Black Greek fraternities and Black churches to find and connect with people who may be in need of counseling services.

The counseling profession should reach out to Black men, he says, instead of waiting for this clientele to “reach out to us.”

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

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

Building trust with reluctant clients

By Bethany Bray June 22, 2022

The Washington Post’s “Dear Carolyn” advice column recently fielded a question from a person who was unsure if they were ready to seek counseling to cope with a strained relationship with a parent. Although the person was aware that counseling could be helpful in this particular situation, they were still reluctant to seek services. “I can’t bear the thought of sharing any sort of emotions or history with a complete stranger, especially when I hear people have to reshare as they try two or several counselors to find the right one,” they wrote.

In her response to this letter, advice columnist Carolyn Hax advocated for the person to try counseling and addressed their hesitancy by saying, “The ‘total stranger’ is actually the point. … That extra, disinterested, trained, and informed set of eyes can help any of us see things we’re too close to see.”

The author of this letter is hardly alone in their hesitance. Data from the National Alliance on Mental Illness indicates that roughly one in five American adults experienced mental illness in 2020, yet less than half received treatment.

And part of this reluctance may stem from the fact that counseling does involves being vulnerable to a stranger — albeit a professional stranger — and working through emotions, trauma and issues that can be painful, sad or fear-provoking. When combined with feelings of shame, stigma or bad memories of a past therapy experience, it’s no wonder that clients are often nervous, fearful or hesitant to start counseling.

Counselors understand the importance of the therapeutic relationship. But when a client is hesitant or reluctant, practitioners need to make trust and relationship building the central focus of counseling work, along with a little extra patience and unconditional positive regard.

An extra dose of validation

Bri-Ann Richter-Abitol, a licensed mental health counselor (LMHC) in New York and a licensed clinical mental health counselor and supervisor in North Carolina, has worked with clients who were so apprehensive about trying counseling that they were visibly shaking in their first few sessions.

Richter-Abitol owns a private practice in Wake Forest, North Carolina, that specializes in counseling for anxiety disorders. She and her staff offer individual and group counseling with a focus on creating a welcoming, nonintimidating environment.

When a client’s body language indicates that they’re nervous or hesitant as they begin counseling, Richter-Abitol uses it as an opportunity to acknowledge their concern and validate that what they’re doing is hard. Her focus becomes normalizing the therapy process, rather than jumping into any kind of assessment or intake regimen.

“This [hesitancy] is extremely common, even for clients who have been in counseling before. … If I notice that a client is really anxious, I use immediacy and point out that it is scary to be here, and I applaud them for coming in,” says Richter-Abitol, an American Counseling Association member.

Clients who are hesitant to try counseling need transparency, patience and an extra dose of validation from their counselor, agrees Megan Craig, an LMHC who counsels clients at a community mental health agency in the Boston area. She often emphasizes to clients that they’re not doing something “wrong” if they are having trouble opening up or aren’t immediately comfortable in therapy. Applauding a client’s bravery to walk through the door also creates an opportunity to ask them what motivated them to make that first appointment — and, in turn, helps the counselor learn more about the client, Craig adds.

Validation played a key part in fostering connection with a female client Craig once worked with who kept being referred to different clinicians within Craig’s agency because of staff turnover.

By the time she was put on Craig’s caseload, the client was “exhausted” and fearful of losing yet another practitioner. So, she had spotty attendance and would often cancel appointments.

“She felt like she hardly wanted to be there [in counseling sessions]. She had told her story so many times, only for her clinician to leave. She kept having to start over from scratch and be vulnerable with a new person,” Craig recalls.

Craig was honest with the client and broached the subject directly, validating that her exhaustion was understandable and warranted.

Craig also realized she needed to slow the pace of therapy with this client. Their early counseling sessions focused on lighter topics, such as work stress. It was one year into counseling before the client was comfortable enough to begin talking about heavier topics, including her trauma history.

The client’s attendance eventually improved but not until Craig spent months building a relationship with her.

“At first, I second-guessed myself and wondered if this [early work] was ‘therapeutic enough.’ But that’s what she needed. That was what was therapeutic for her,” Craig says. “She needed to establish the trust that I wasn’t going to leave and would stay with her. Just me showing up [to counseling sessions] is exactly what this client needed.”

Fear of judgment

Counselors are no strangers to the importance of the therapeutic relationship, and decades of research show how central and essential it is to client engagement and growth, says Michael Tursi, an LMHC in New York. Counselors, however, must make relationship building an utmost priority for clients who are hesitant. They have an opportunity to display nonjudgment every time they respond and interact with a client, he notes.

“It’s one thing to say, ‘the therapeutic relationship is essential,’ but there are some clients who really might not be willing to engage at all until they see certain things, especially nonjudgment, in their counselor,” he says. “When counselors meet with clients, right from the beginning, they have an opportunity to display nonjudgment.”

Tursi, an assistant professor in the mental health counseling program at Pace University’s Pleasantville, New York campus, has done research on client experiential avoidance (i.e., when a person is resistant to experiencing strong or adverse sensations, emotions or thoughts) and engagement in counseling. For his doctoral dissertation, Tursi interviewed a cohort of clients in counseling who self-identified as experiencing this phenomenon, and he, along with two other colleagues, published the findings in a 2021 Journal of Counseling & Development article.

Tursi measured his study participants’ level of avoidance by having them complete the Multidimensional Experiential Avoidance Questionnaire developed by psychologist Wakiza Gámez and colleagues.

According to Tursi, one data point in his research quickly became very clear: Each and every one of the participants talked about fear of judgment from their counselor. The study participants acknowledged that they became more engaged in counseling once they established that their counselor was trustworthy and nonjudgmental.

In fact, the participants viewed counseling as a potentially harmful or threatening relationship until their counselor had fostered a trusting relationship with them and eased their hesitancy, Tursi adds.

Some participants talked about “testing” their counselor by intentionally saying something to elicit a response to gauge how trustworthy the counselor was. Even if a client does not do something like this intentionally, Tursi notes, they are very aware of how a counselor is responding to them.

“Nonjudgment is central to working with any client. But these clients might need a counselor who is quite in tune with [the fact that the] client is concerned about judgment and be patient with that,” says Tursi, an ACA member.

A key aspect of creating an atmosphere of nonjudgment is for counselors to be aware of a client’s comfort level, he says. This includes keeping an eye out for indicators that a client is anxious, such as body language, and checking in regularly with the client to talk about how they feel things are going.

A client should never feel pestered or pushed into talking about issues; they should come to the decision to disclose on their own, Tursi emphasizes. Counselors need to temper the expectations of what they think or expect a client will need or be willing to do.

“Attending to where your clients are is important. We shouldn’t go into therapy and assume clients are going to disclose right away rather than do the therapeutic work that we think they need to do,” he explains. “Counselors should make sure they’re focusing on providing conditions for these clients to engage. … The client is never going to get there [make progress], in any kind of meaningful way, unless they’re engaging in sessions.”

Tursi hopes his research spreads awareness among counselors that experiential avoidance is very common and that some clients may come into counseling believing — for a variety of reasons — that it could be a relationship that is potentially harmful. Tursi draws on the work of Barry Farber, a professor of psychology and education at Teachers College, Columbia University, when he emphasizes that it’s easy to have unconditional positive regard for clients who come in ready to trust and work with their counselor. But it’s equally important to provide that regard for clients who are hesitant, although it may be more difficult. Patience should be a counselor’s watchword, Tursi adds.

“As counselors, we have to be aware of situations in which we have difficulty providing positive regard and continue professional development to improve our abilities to provide nonjudgmental acceptance at times that it is difficult,” Tursi says.

Check yourself

As a practitioner who specializes in counseling clients with anxiety, Richter-Abitol finds that rapport building with clients who are hesitant must involve self-awareness on the part of the clinician. This includes keeping her own wants, expectations and assumptions about work with clients in check, she says, and asking for client input on the pace and direction of their treatment.

Richter-Abitol is transparent with her clients: She lets them know that they are “in control” of what they want to talk about in sessions and emphasizes that she won’t “make” them talk about anything they’re not ready to.

“You have to meet the client where they’re at and let them set the agenda. I have had clients who have taken months to build rapport, and if you [the counselor] are not patient, you may never get to that point,” Richter-Abitol says. “You have to constantly check yourself outside of sessions and tell yourself that even small successes contribute toward long-term goals. Small things add up.”

polkadot_photo/Shutterstock.com

Richter-Abitol, like Tursi, argues that the therapeutic relationship must take priority with these clients, rather than diving into a treatment plan based on their diagnosis or what the practitioner thinks they need. Counselors should get creative to find ways to bond with the client prior to moving into heavier work, she suggests. For young clients, this might be therapeutic games or activities; for adults, it might be a discussion of lighter topics that help paint a picture of who they are, including things that they like, dislike and what motivates them.

“Those conversations can lead to deeper ones,” she says. “It’s not helpful to be too rigid. You can have things that you’d like the client to work on, but ultimately it has to be up to them. Flexibility is important.”

Richter-Abitol has found that clients feel more empowered when she lets them take the reins in this way. And many begin to open up naturally when they don’t feel pressured to do so.

This approach requires counselors not only to be in touch with and sensitive to their client’s needs and level of readiness in counseling but also to check their own inclination to take charge when a client is slow to make progress. It’s all too easy to assume that a client who isn’t making progress — or not progressing in a way the counselor might want or expect — isn’t benefiting from counseling, Richter-Abitol notes.

Instead, she advises practitioners to take a step back and consider the client’s full context, including the barriers and challenges that are making it difficult for them to engage with a counselor.

“Their fear or discomfort can come off as resistance or presenting a vibe that ‘I don’t want to be here.’ … They just don’t know how to feel about this space yet, and you need to give them time to figure that out,” Richter-Abitol says. “Don’t make the assumption that someone who is uncomfortable isn’t gaining anything from the experience. It might not be that they don’t want to be there but they just don’t know how to be there yet.”

Have honest conversations

If patience is the first thing that clients who are hesitant or slow to engage in counseling need from a practitioner, transparency is the second. For Craig, this comes in the form of direct questions to the client to gauge their comfort level and an honest invitation to let her know when things aren’t working.

If a client appears uncomfortable or is hesitant to engage in counseling, Craig will address it directly, saying, “Here is what I’m picking up on. Tell me if I’m right or wrong.” She emphasizes to clients that she cares for their well-being and genuinely wants to hear how they’re feeling — and that they have a choice and a say in the counseling process.

Sometimes what counselors view as resistant behavior in clients can be caused by the use of methods or techniques that aren’t a good fit for that individual, Craig says, or it can be that the practitioner themselves is not the right fit. Because clients may not bring up problems to a counselor on their own, she makes a point to broach the topic with honesty, explaining that no therapist is going to be the best match for everyone who walks through their door.

“If someone is taking the huge step to start counseling, I want them to benefit from it as much as possible. I’m honest and tell them that they’ll never make progress if we are not a good fit,” says Craig. “People are not ready for different reasons, and that’s why I like to have such open conversations. … I might not be able to give them everything they need, but I certainly want to talk about it and I want to try.”

She not only checks in regularly with clients throughout therapy but also makes time for a deeper conversation about what is and isn’t going well once a year (on their anniversary as her client).

During these check-ins, she prompts clients with questions such as:

How do you feel about our work together?
Do you respond well to me taking the lead in counseling, or do you prefer to take the lead?
What has been helpful during our work together?
What do you need more of? And less of?
What did you expect from therapy and how has this not met your expectations?
What’s working and what’s not?

Not only do these conversations provide Craig with valuable feedback, but they also help set an example for the client to advocate for their own needs outside of counseling, she notes. Learning to be able to communicate their needs and expectations is a big — and important — milestone for many clients.

Craig recommends clinicians ask clients directly about how things are going in counseling rather than fall into an easy pattern of making assumptions about individuals who are avoidant or hesitant to engage. Honest feedback from a client is a good thing, Craig stresses, and not something that a counselor should take personally.

Overcoming cultural barriers

Counselors also need to take a proactive approach when clients are hesitant because of challenges and barriers related to their cultural background, says Camila Pulgar, a licensed clinical mental health counselor associate who is a research faculty member at Atrium Health Wake Forest Baptist Medical Center in Winston-Salem, North Carolina.

Building trust and forging connection with clients who are from marginalized cultures require a counselor not only to be comfortable broaching the subject of culture (and cultural differences) in client sessions in an ethical and compassionate way, Pulgar says, but also to be fully aware of and sensitive to the many barriers that keep them from accessing counseling or being fully comfortable in the setting.

A native of Chile, Pulgar specializes in the mental health needs of Latinx clients, including suicide prevention. She does clinical work once a week in her faculty position at the medical center, and she is the only bilingual (Spanish/English) provider on her team. Being the only bilingual counselor is not unusual for Pulgar; in fact, this has been the case for most of her professional career, she says. The mental health care system in this country is simply not built to support the needs of clients whose first language is not English.

Language is only one of many barriers that can deter clients from minority cultures from seeking or becoming fully engaged in counseling, Pulgar points out. Individuals may face logistical challenges such as trouble accessing transportation to appointments, finding child care or affording the cost of sessions. They may also be fearful or have adverse feelings about counseling because of stigma, past harm or skepticism about therapy within their culture or family group.

“If people make it to my office, they’re usually hesitant to share their mental health journey with their family members because of stigma. I often hear ‘I don’t want anyone else to know I’m here’,” says Pulgar, who also sees a small caseload of clients at her private practice in Winston-Salem, North Carolina. “When we talk about their supports and who they can reach out to in times of crisis, they often don’t list anyone [in their family] because they don’t want their family to know they’re struggling.”

Shivonne Odom, a certified perinatal mental health provider whose private practice is the only practice in the Washington, D.C., area that specializes in perinatal mental health care and is owned by an African American therapist, says this is also common among her clients, the majority of whom are African American.

She’s had clients whose families reacted very negatively when they found out the client was attending therapy, and other clients have chosen not to disclose the fact that they were seeking counseling to their families and, in some cases, even their spouse.

Hesitancy is very common among Odom’s clients; she recently had a client tell her that she needed to take an hour-long walk to calm her nerves before logging in for her first counseling session.

There is an extra layer of stigma for minority clients who are seeking perinatal mental health care because pregnancy and childbirth are often assumed to be a joyful and happy time — not one of despair. All of these challenges add up and severely affect clients’ help-seeking behaviors, says Odom, a licensed professional counselor in Washington, D.C., and a licensed clinical professional counselor in Maryland.

Pulgar notes that conversations around challenges in minority mental health care often place the blame on the stigma that many cultures have regarding counseling. In reality, minority populations face many barriers when seeking treatment, and that should be an equally, if not more, important part of the discussion.

This issue is compounded by the fact that most of the evidence-based treatment methods that students are taught in graduate counseling programs were created by and tested within members of the majority population. So, it makes sense that many of counselor’s go-to methods may not be a good fit for some minority clients, says Pulgar, an ACA member.

Clients can also become discouraged if they are referred to counseling by a medical provider and none of the counselors on the referral list look like the client, Odom adds. Because of this, she goes out of her way to accept many different types of insurances and often consults and works with multidisciplinary professionals in related fields, such as lactation consultants, to advocate for her clients and ensure that other providers know of her services.

Counselors should also be aware that these clients are often unfamiliar with the process of counseling. A first step toward forging a therapeutic connection can be to explain what therapy is (and isn’t) and why it’s helpful, along with the concepts of privileged information and confidentiality, Odom says.

Pulgar and Odom emphasize that one way to reduce these clients’ stress and barriers to treatment is for counselors to become knowledgeable of culturally connected resources in their area, such as nonprofit organizations and support groups and services.

Free support groups can be very helpful to validate a client’s feelings and experience in a way that individual counseling can’t, Odom says. And if there isn’t a group that matches your clients’ culture and identity (e.g., single mothers by choice), she suggests that counselors consider seeking training to start and lead one.

It’s equally as important for counselors to forge a connection with the marginalized community in their area as it is to build a strong therapeutic relationship with individual clients, Pulgar says. She suggests that practitioners start by becoming involved with organizations that serve the local marginalized community and participate in events such as health fairs.

“Get out of the four walls of the office,” Pulgar stresses. “Marginalized communities are so collective, and community is an important part of life.”

Small changes, big impact

Counselors have an opportunity to build trust with a client with every interaction. And sometimes, seemingly “small” things that are outside of the core work of counseling can make a big difference to a client. Here are just a few small steps clinicians can take that will make a big impact on clients.

Explain the process of counseling and why it’s helpful. Don’t assume that clients know what therapy is or what it entails, Tursi advises. “If they’ve never been to counseling previously, the idea of connecting with feelings might be very foreign to them,” he says. “They might start counseling thinking that the counselor can just make these [difficult] feelings go away. When instead, counseling [works to] change their relationship with their feelings — and a practitioner may need to explain that.”

Remember that a breakthrough does not mean clients are completely comfortable in counseling. A counselor whose client makes a significant gain toward trusting their practitioner in one session may feel that they’ve built their relationship enough to move on and address other issues. However, the only way to truly build trust is to have patience and show a client, over time, that you are trustworthy, Craig says. This is especially true for clients whose trust has been broken by others in their life, including health care providers. “Remember that even if they open up about their fears, it doesn’t mean they’ll be less fearful at the next session,” she adds. “It’s about patience and giving them that chance to warm up.”

Welcome clients before they even sit down. Forging trust with hesitant clients takes “more than what you are doing in the [counseling] room, it’s the whole experience,” Richter-Abitol says. “And we want to make people feel as welcomed as possible. … I know what it takes to walk through that door, and how hard it can be.”

She has taken client comfort into consideration in every aspect of her practice, from choosing cozy décor for the waiting room to a casual staff dress code. She built her website to be particularly user-friendly and extend a welcoming vibe before clients even set foot in the door. For example, she provides a detailed biography of all members of the clinical team, including photos of the practitioners, adjectives that describe them (e.g., bubbly, enthusiastic, loyal, creative, motivated) and a description of what a client can expect when working with them.

“We try and dial down the clinical and dial up the parts of our personality” on the website to make potential clients feel comfortable, Richter-Abitol explains. “With the anxiety population, fear of the unknown is a big issue, so seeing the office and the pictures [online] helps fills in that space [and] helps people form connections before even coming in.”

Pronounce their name correctly. And if counselors are not sure how to pronounce the client’s name, they should ask and remember it, Pulgar says. This is a seemingly small thing that can be overlooked by practitioners, she notes, but it lets the client know that a counselor values their identity.

Don’t assume they’re resistant. Clients who are opposed to treatment and those who are hesitant or slow to engage in counseling can exhibit some of the same behaviors, such as canceling appointments frequently, answering a counselor’s questions with one-word answers or avoiding talking about heavier topics. However, counselors have an opportunity to build trust and explore the reasons why a client appears reluctant, rather than labeling them as resistant.

“We have been taught [in counselor trainings and graduate programs] that it’s a normal way to view clients. It’s really discouraging to know that [the word ‘resistant’] is even part of the dialogue,” Craig says. “Just because your perception as a clinician is that a person is not trying doesn’t mean that they’re not trying. They might not be doing the homework you assign, but they’re showing up every week. And that may be all that they can do right now. That is trying for them. Be sensitive to what they need to make progress.”

Do no harm and seek training. An important aspect of building trust with hesitant clients is ensuring that a practitioner is providing ethical, appropriate and competent care to keep from exacerbating their hesitancy or repeating any bad experiences they might have had previously in therapy. This includes seeking training, consultation or supervision when a counselor has a client who comes from a culture or is dealing with a challenge that the counselor is not familiar with.

In the case of perinatal clients, clinicians who are not trained in the needs and nuances of work with this population risk providing inaccurate — or even harmful — care, Odom says. Some of the symptoms that can be common in perinatal clients, such as intrusive thoughts about harming their baby, can easily be misinterpreted, she explains.

[Hear more on this in an ACA podcast episode featuring Odom: “Counselor Advocacy with Maternal Mental Healthcare.”]

“We [counselors] have an ethical duty to only practice in areas in which we are trained, and if we’re not, we have an ethical obligation to reach out to providers who are and consult with them,” Odom says. “Don’t be afraid to take a training on perinatal [mental health]. I have seen way too many clinicians treating these clients [inappropriately] and it leads to clients having to unjustly interface with systems that will do harm.”

Leave the door open for them to return. Clients who are hesitant about counseling are more likely to drop off a practitioner’s caseload. Counselors should take measures to focus on retention with this client population, but they should also understand that when the client stops counseling, it doesn’t mean that it wasn’t beneficial. Sometimes people simply have so much going on that life “gets in the way” and they can’t come to regular sessions, Pulgar points out.

Practitioners should emphasize to these clients that they’re always welcome to return to counseling whenever they’re ready. Instead of placing blame and asking the client not to return after missing multiple sessions, a counselor can instead say, “I understand this may not be the best time to start counseling in your life, but please do reach out when it is. I am here for you, please keep my number,” Pulgar says.

“The truth is, not everyone is ready for counseling when it comes time for the appointment, even if they made the phone call [to schedule]. They may not be ready to engage yet in the process of what counseling demands,” Pulgar says. “Stay calm and don’t overthink ‘What am I doing wrong?’ or ‘What more can I do?’ Take a couple of deep breaths and think about ways that the door stays open. … If clients get a good sense of counseling just with that interaction with you, maybe in a year or five years, they will come back. That interaction, although brief, can give them a positive feeling about counseling.”

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Reasons why

Many different factors and barriers deter people from seeking counseling or feeling comfortable in sessions. This is by no means an exhaustive list, but some common client fears and concerns include:

The client (or someone they know) has had a bad, hurtful or unhelpful experience previously with a mental health or medical practitioner.
They come from a culture where counseling is not widely accepted or a culture that has been historically maligned or harmed by mental health professions.
They are struggling with an issue that involves feelings of shame.
They are afraid to confront the issue they are struggling with; this can include hesitancy to relive trauma as they process it or fear of showing vulnerability or imperfection.
They fear being given a diagnosis and/or being misdiagnosed.
They worry the counselors will judge them.
They fear meeting and opening up to a person they don’t know.
They experience overwhelming negative or catastrophizing thoughts (e.g., “Counseling is not going to work”).
They face logistical challenges (lack of insurance or inability to pay, trouble finding child care or transportation, etc.).
They worry that others (family, peers, etc.) will find out they are attending counseling.
They do not have a choice in attending counseling (e.g., a person who is mandated to complete therapy, often as the outcome of a court case).
They are hesitant or unable to connect with a practitioner who doesn’t come from the same background or experience as them (e.g., a Latinx or LGBTQ counselor, one who has served in the military, one who understands miscarriage and infertility).

This information came from interviews with the following counselors: Megan Craig, Shivonne Odom, Camila Pulgar, Bri-Ann Richter-Abitol and Michael Tursi.

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

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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.