Tag Archives: Assessment


Voice of Experience: The danger of misinterpreting risk  

By Gregory K. Moffatt   September 28, 2023

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

Fida Olga/Shutterstock.com

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

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

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

Violence in psychiatric hospitals 

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

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

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

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

Misleading data 

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

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

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

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

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

Recognizing real vs. perceived threat  

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

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

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

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

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

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


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

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

Taking a culturally responsive approach to suicide assessment

By Lisa R. Rhodes September 6, 2023

A woman sits on a couch looking worried with hands covering mouth and nose. Across from her is a woman with a notepad and a pen.

PR Image Factory/Shutterstock.com

Although the overall suicide rate in the United States has been decreasing in the past few years, death by suicide among people in marginalized groups has been increasing at an alarming rate. According to data by the Centers for Disease Control and Prevention (CDC), American Indian and Alaska Native people had the highest suicide rate increase from 2018 to 2021 at 26%. Although the second highest suicide rate was among non-Hispanic white people, this was the only group to show an overall decline by 4%.

Other marginalized groups, particularly among youth and men, indicate areas of concern for mental health professionals. According to the CDC, suicide rates among Black youth age 10 to 24 increased 37% from 2018 to 2021, and the suicide rate among Hispanic men increased by 5.7% from 2019 to 2020, while the suicide rate among non-Hispanic white men decreased by 3.1%. Among Asian American and Pacific Islander communities, suicide was the leading cause of death for people ages 10 to 19 in 2020.

Heather Dahl-Jacinto, an assistant professor and counseling program coordinator in the Department of Counselor Education, School Psychology and Human Services at the University of Nevada, Las Vegas, says while clinicians should not generalize about the experiences of marginalized groups, researchers have found that there is an association between historical and racialized trauma and suicide risk.

“For those with marginalized intersectional identities (such as race/ethnicity, sexual orientation, social class, gender identity), there is an increased pattern of suicide risk in individuals,” she explains. “Understanding the intersectional identities of our clients and their own lived experience is vital to our work with clients.”

Socioeconomic factors associated with suicide

The COVID-19 pandemic and social injustices may have contributed to the rise in suicide rates in the past few years, especially among marginalized groups. Karlos Lyons, a licensed professional counselor (LPC) at Davis Counseling Center PLLC in Dallas, says during the pandemic the Black community struggled to come to terms with social isolation, loss of loved ones, ongoing health disparities and the racial unrest that spread worldwide in the wake of the murder of George Floyd.

Ana Sierra, an LPC in Washington, D.C., says many of her Latinx immigrant clients, who work as essential workers, were among the first to get sick with COVID-19. She notes these clients suffered because they lacked access to health care and lost their jobs when they got sick, which forced many of them to lose stable housing.

“Latinx men have a particularly hard time because in their gender role, seeking help or talking about their worries with others is a sign of weakness,” notes Sierra, founder and executive director at Ana Sierra Counseling/Consejeria PLLC, an all-Latinx, bilingual (English/Spanish) and bicultural group practice. When Latino men, who are viewed as the head of their household, cannot fulfill their responsibilities to their families they don’t feel validated and can be hit by intense feelings of uselessness, she explains.

“In the Asian community, we have experienced an increased risk of suicide among Asian Americans due to systemic factors during the pandemic,” says Wales Khoo, a licensed mental health counselor in New York and the clinical director at the Chinese American Sunshine House, a nonprofit that provides mental health services for the Chinese community. “These factors include economic hardship, financial insecurity, racism, discrimination, hate crimes and limited access to health care.”

In addition, immigrant youth may face significant pressure from their families and communities to excel academically, Khoo says, which can lead to mental health issues such as stress, anxiety and depression. This pressure is particularly intense for first-generation immigrants who “may feel their success or failure reflects on their family’s reputation,” he adds.

“Many Asian American youths also experience acculturation stress as they navigate the challenges of living in a culture that is different from their parents’ or their family’s culture,” Khoo says. “Conflict between generations or between cultural values can contribute to feelings of isolation, depression and suicidal ideation.”

Research shows systemic socioeconomic factors — specifically racism, discrimination and adverse childhood experiences — directly affect suicide rates among people of color, notes Dahl-Jacinto, whose research areas include suicide prevention and assessment and social justice issues in professional practice. In addition, these factors can prevent marginalized clients from seeking mental health services as they seek to thrive in a society that presents persistent obstacles.

The counselors interviewed for this article recommend counselors be open to learn about a client’s lived experience, which will help people from marginalized communities feel safe enough to trust the therapeutic process and make it easier for counselors to thoroughly assess for suicide risk.

Cultural responsiveness requires counselors of all backgrounds “to gain an understanding of the client’s worldview and experiences in concert with the client,” says Danica G. Hays, a professor of counselor education and educational psychology and the dean of the College of Education at the University of Nevada, Las Vegas. And this includes validating any experiences of oppression and disempowerment that clients may report. “Those experiences are real and can exacerbate any mental health issues a client may be facing,” she stresses.

Building rapport

Recent clinical research about suicide risk assessment and intervention shows that focusing on the counselor-client relationship and cultivating trust and rapport can go a long way when dealing with a difficult topic such as suicide, Dahl-Jacinto says. She stresses the importance of not making assumptions about a client’s personal identity; instead, she advises counselors to use the strategy of broaching in session to create a safe space that allows clients to feel comfortable sharing their story.

“When working with communities that are traditionally marginalized, making sure that the counselor is intentionally acknowledging these concerns is essential to building rapport,” she explains.

Suicide risks are multifaceted, notes Lyons, who specializes in treating Black adolescents age 12 to 18. Some young Black men, for example, may struggle with hypermasculine ideals that “dictate to them not to feel or process their emotions because they are boys,” he says, noting that these clients often report having trouble connecting with others and dealing with feelings of worthlessness.

Lyons says it’s important to help these young men find others who can serve as healthy role models. “Once a young man has a positive, corrective, emotional experience with another male role model, whether it be a father, uncle, friend or even a peer, typically their mental health outcomes improve,” he explains. “They now have a safe place where they can go for validation and approval.”

Counselors need to model unconditional positive regard for their clients to build rapport with them, Lyons adds.

“When broaching the topic of suicidal ideation, look for the root cause of ideation, rather than the symptoms,” he advises. “I like to use Abraham Maslow’s hierarchy of needs to assess what needs are not being met that may have led to mental health distress.” Lyons says many adolescents have experiences in school such as poor school performance, bullying, a lack of friendships and isolation, which may lead to them becoming more suicidal.

Lyons also uses age-appropriate games as a therapeutic tool to encourage dialogue with his clients. For example, he sometimes asks clients to play the Ungame, a noncompetitive board game that requires players to answer lighthearted or serious questions as they roll the dice and move around the board. “It fosters organic dialogue between the therapist and client, and it facilitates really healthy conversations that can lead to some extremely helpful therapeutic content,” he notes.

Lyons, who is a Black man, says that simply “showing up as a Black man” can often help him gain his clients’ trust. For many Black youth, working with a clinician who looks like them and lets them know they are the expert on their own lives often helps them feel comfortable to “share their own truth,” he says.

The majority of Sierra’s clients have immigrated to the United States, and she says they often do not understand how the country’s mental health system works. She uses psychoeducation to explain what therapy is, how it can help, the difference between having suicidal thoughts and a suicide plan, and the stigma of mental illness and suicide. She says the clinicians at her practice also discuss any fears clients may have about being treated for suicidal behavior and their immigration status. For example, immigrant clients are less likely to seek treatment because they fear it will affect their chances of becoming documented in the future or they fear being deported, she says.

The therapists at Khoo’s clinic also adopt a culturally sensitive approach that acknowledges and respects clients’ cultural background and values. Because suicide is frequently regarded as a taboo subject in the Asian community, he and his colleagues, who treat primarily Asian American and immigrant clients, address the Asian community’s apprehension and worries about suicide by creating a safe and comfortable atmosphere, as well as encouraging family engagement, which are important elements that aid in healing.

Demonstrating a genuine acceptance of a client’s struggles with oppression helps to build rapport and trust, says Hays, author of the recent ACA book Assessment in Counseling: Procedures and Practices (seventh edition). Counselors are then able to “define the broad spectrum of what suicidality is and note the relevant statistics based on the client’s cultural makeup.”

It’s also important to help clients see that many other people face suicidality and that through treatment, clients have access to resources that can help them to heal, she adds.

Evidence-based assessment tools

Dahl-Jacinto and Hays acknowledge that while no suicide risk assessment tool is free from cultural bias or is completely culturally responsive, there are some evidence-based, standardized suicide risk assessment tools that can be used to evaluate a variety of clients. The counselors interviewed for this article recommend the following assessment tools:

  • The Columbia-Suicide Severity Rating Scale helps physicians, mental health clinicians and other health care professionals assess suicide risk using a series of simple, plain-language questions. The Columbia Lighthouse Project, which distributes the scale, provides free training.
  • The Collaborative Assessment and Management of Suicidality is an assessment and intervention framework where the client plays an active role in identifying and addressing the drivers of suicide risk.
  • The Ask Suicide-Screening Questions assessment, produced by the National Institute of Mental Health, can be used for both adults and youth of all ages and provides four brief, direct questions to identify suicide risk. This assessment is also available in Spanish.
  • The Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 are self-administered assessment tools that assess the severity of depression and anxiety, respectively. Sierra recommends clinicians use the Patient Health Questionnaire-9 to learn more about a client’s symptoms and any suicidal thoughts and feelings they may be experiencing.

Because of the link between trauma and suicidality, Hays also recommends counselors conduct a trauma assessment. She suggests clinicians use the Adverse Childhood Experience Questionnaire for Adults or the Clinical Ethnographic Narrative Interview.

The counselors interviewed for this article advise clinicians to make suicide risk assessment a part of the intake process. Providing a comprehensive psychosocial evaluation allows practitioners to explore a client’s personal and family history, their social support network and other environmental factors, Khoo says, which helps clinicians gain a full picture of a client’s mental state and well-being, not just the symptoms they present in session. The evaluation can also give counselors insight into a client’s cultural traditions, spiritual beliefs and value systems, which can be useful in the assessment process and creating treatment and safety plans, he adds.

Protective cultural factors

A client’s cultural traditions and spiritual beliefs are important to consider when assessing suicide risk and are also an essential part of building a strong therapeutic alliance. Dahl-Jacinto says when counselors are working with clients who are experiencing suicidality, they want to make sure they have a good idea of potential protective factors in the client’s life, including ones from their cultural traditions or spiritual beliefs.

“I like to use the building blocks metaphor that we use in suicide research — each protective factor we can identify acts as a building block that builds a wall around our client, protecting them from harm,” Dahl-Jacinto explains.

Khoo says in some Asian communities, cultural traditions, religion and spiritual beliefs play a significant role in people’s lives. “Many Asian cultures have unique beliefs and practices around mental health and suicide, and incorporating these into the treatment process can help build rapport, enhance treatment engagement and increase the client’s sense of hope and resilience,” he notes. For example, therapists at Khoo’s practice might use storytelling, art or music to facilitate a dialogue and help clients connect with their cultural heritage, which can help them build a sense of pride and identity.

Sierra says the clinicians at her practice normalize talking about suicide and make counseling a safe and welcoming space for clients — one that is similar to how clients might seek guidance from pastors, folk healers and others in their community. “A therapist,” she stresses, “is one more helper in their circle.”


Suicide risk and prevention resources


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

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

Voice of Experience: Disorders with the potential for dangerous outcomes

By Gregory K. Moffatt August 30, 2023

A person's feet in sneakers standing on a street before the word caution written in yellow chalk

Photo by Goh Rhy Yan on Unsplash

My first trip to a psychiatric hospital was in 1978. I was a first-year college student, and one of my classes toured a state-run hospital. Like my classmates, I’d seen plenty of movies about a scary “crazy” person who escaped from a hospital and terrorized the community. But I learned on that trip — and my career experience has shown it to be true — that most people in hospitals like that came in on their own accord for help.

Our guide, the director of the facility, noted that the fence around the gigantic property was not there to keep the patients in, but rather it was there to keep others out. In fact, many of the patients in that facility could have walked out the front door any time they wanted. But they didn’t want to. They wanted help.

This trip reaffirmed what I have found to be true in my work with clients throughout my career: Most people with a mental illness are not dangerous. In fact, they are often more of a danger to themselves than others. But there are a few mental illnesses that can have potentially dangerous outcomes for others.

Three disorders associated with an increased risk of violence

Research is weak regarding which mental illnesses are correlated with dangerous behaviors. I’ve researched this area for close to 40 years, and I can assure you there is no simple answer. But here are three disorders that have the potential for dangerous outcomes and always give me cause for concern.

Reactive attachment disorder. In terms of dangerousness, reactive attachment disorder is the king. This disorder, which affects children, is one of the scariest due to the developmental limitations in children in terms of coping skills and problem-solving.

I’ve seen these children cut, pinch, hit, and even kill infants and young children. I’ve seen cases in which children as young as five years old have threatened their guardians with knives. I’ve had clients under the age of seven sexually assault younger children, and I’ve seen older children with this disorder kill family pets as well as rape adult women. Children with this diagnosis need 24/7 supervision along with intensive treatment plans.

Antisocial personality disorder. Antisocial personality disorder is the adult cousin of reactive attachment disorder. Clients with this disorder can exhibit their dysfunction in several ways. One key characteristic is that people with this disorder manipulate people. They can do this in a variety of ways, some of which don’t include violence.

But clients who choose to manipulate others physically or sexually can be dangerous. They have little compunction regarding the injury they cause others. The desire to manipulate others and see pain can lead to horrifying behaviors. These patients will attack staff or fellow patients in hospital settings, and they can easily attack therapists in outpatient settings. Individuals with this disorder are often the characters many of us know of as serial killers and serial rapists. Much of what I’ve seen of these individuals over my career is not far flung from the movies.

(For more on this disorder, see my article “Counseling encounters with the puppet masters,” which was published in the February 2019 issue of Counseling Today.)

Delusional disorders. My wife and I visited a restaurant in downtown Atlanta recently. As we approached the restaurant, I saw a man pacing back and forth on the sidewalk in front of us near the front door. He was clearly homeless and suffering from delusions. We gave a wide berth to the guy as we entered, but from our table, I could still him through the window. It grieved me to watch this gentleman outside the restaurant suffering in front of me.

As with antisocial personality disorder, individuals with delusional disorders exhibit their symptoms in a variety of ways. Only some of their expressions are dangerous. The sensory hallucinations (auditory, tactile, visual, etc.) that these clients experience are absolutely real to them.

But unlike antisocial personality disorder, these individuals are not dangerous out of spite or cruelty. Instead, the delusions they experience and the chaotic worlds in which they live can cause them to feel threatened and, in response, act out. This is why I steered clear of the homeless man as I entered the restaurant.

In other cases, their delusions lead them to think they are helping when they are doing the opposite. For example, Russell Weston, a 42-year-old man with schizophrenia, killed two Capitol police officers in 1998. He believed he was saving the world from aliens and was trying to access the “ruby satellite” he believed to be housed in the U.S. Capitol.

Violence risk assessment tools

Assessing dangerousness is a complicated process and an inexact science, and this can cause some mental health professionals to worry about assessing and treating clients with these disorders. But there are clinical tools that can help clinicians better assess the risk of potential violence.

I developed the Violence Risk Assessment Checklist in the 1990s (available at gregmoffatt.com) and have used it for years in businesses. This hierarchical checklist, like a suicidal ideation checklist, helps counselors evaluate for increased or decreased risk of potential violence. It contains twenty-eight items. Of the top eight, the more items the counselor checks when assessing the client, the higher the risk of violence.

The National Institute for Occupational Safety and Health provides a list of violence risk assessment tools that have been developed specifically for determining a person’s potential for violence to themselves or others. This list includes the Dangerousness Assessment Tool, which is a quick assessment scale clinicians can use to determine if an individual who is displaying signs of potentially dangerous behavior is a risk to others.

Clinicians need to realize, however, that just like assessing for risk of suicide, these instruments are only guides for decision-making and intervention, not precision tools.


Next month, I’ll address who isn’t dangerous and how I know.


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

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

Behind the Book: Q&A with Danica G. Hays

August 24, 2023

Assessment in Counseling book cover beside a close-up image of two people sitting across from each other taking

ACA recently released the seventh edition of the best-selling book Assessment in Counseling: Procedures and Practices. This revised edition includes new and expanded content on assessment and qualitative and quantitative approaches that can be used in face-to-face and telehealth counseling settings. Counseling Today spoke to Danica G. Hays, a professor of counselor education and educational psychology and the dean of the College of Education at the University of Nevada, Las Vegas, about what inspired her to write the new edition and how the proper assessment of clients can help build the therapeutic alliance.


What is assessment in counseling?

In our profession, the term assessment is often erroneously used interchangeably with the term testing. When I began training and then working as a professional counselor, I learned quickly that assessment is so much more than testing. It is all the procedures and practices that occur informally and formally as the counselor and client engage in counseling. In addition, assessment is a tool for relationship building that can happen with both the client and their community. Essentially, assessment is counseling practice.

What prompted you to revise this book now and how does it differ from previous editions?

Danica Hays headshot

Danica G. Hays, author of Assessment in Counseling (seventh edition)

I am excited to have the seventh edition available to emerging and seasoned counselors. In general, this text has been a part of my life since I trained as a professional counselor and taught an assessment course early in my career, using the third and fourth editions of the text, respectively, co-authored by Albert B. Hood and Richard W. Johnson. Hood and Johnson were instrumental to my own learning and teaching. They provided such a strong foundation for the text, and I remain humble to be able to author and revise the text’s fifth, sixth, and now seventh editions.

The seventh edition emphasizes that assessment procedures and practices are integral components of counseling throughout the counseling relationship and that they can be culturally responsive to support client and community well-being. In addition, counselors will learn how qualitative and quantitative approaches can be used across in-person and telehealth counseling settings.

What are the benefits of engaging clients in the assessment process?  

Because the assessment process is counseling practice, it is embedded in the work we do every day with our clients and communities. Thus, we engage in assessment procedures and practices in our work whether we recognize it or not. With this awareness, counselors can increase their knowledge of available assessment approaches and be intentional with their use throughout the counseling process to address presenting concerns and support overall wellness.

Assessment procedures and practices have several benefits. As a process within a counseling session, effective assessment processes can foster client self-awareness of both their challenges and their strengths and areas of resilience. They can facilitate the counseling relationship, which in turn can yield optimal outcomes for the client, such as wellness and self-empowerment. Furthermore, they can help to identify new ways of understanding mental health, resilience and social justice concerns experienced by culturally and linguistically diverse clients and communities.

Assessment processes can also extend outside of the traditional counseling session. For example, when counselors use assessment approaches such as community asset mapping or other social justice-oriented approaches, they better understand how communities can be assets for client well-being as well as their own professional and personal growth. Finally, knowledge gained from the assessment process can help inform counselors’ work with community stakeholders, other practitioners and policymakers, which ultimately advances counseling practice and our profession in general.

How has telehealth affected the way counselors assess clients?

A silver lining of the COVID-19 pandemic has been the increased use of telehealth, which allowed for cost-effective and accessible assessment processes to persist during social distancing. Before the pandemic, however, telehealth was an invalu­able resource to reach clients who are traditionally underserved, such as those in rural settings, those with disabilities and those of other marginalized statuses.

Counselors who deliver telehealth assessment and counseling have a wide array of technologies available to them: telephone or video calls to provide services synchronously, wearable devices, text-based mobile health interventions, chatbots and e-consultations to support clients asynchronously. These technologies can increase access to the assessment process, but counselors also need to be sensitive to the fact that some clients may not be able to use telehealth because of a lack of access to technology or a general digital divide.

How does implicit bias affect mental health assessments?

We all have implicit bias — the attitudes and stereotypes we hold about ourselves and others — and it affects our personal and professional interactions every day. Implicit bias can be positive or negative and is based on our own cultural experiences. It can lead to discrimination or harmful behaviors based on negative attitudes held about a cultural group. Racism, sexism and other forms of discrimination (e.g., heterosexism, classism) occur in assessment when counselors use cultural group membership as the explanation for assessment findings. In other words, the counselor says that race or other cultural markers cause sys­temic differences, alluding to minority group membership as deficient in some man­ner.

The impact of implicit bias — through acts of discrimination — has sustaining effects that extend beyond an assessment finding. For example, research in school settings demonstrate that implicit bias can impact student learning, lead to improper placement in special education, yield harsher disciplinary actions (e.g., suspensions, expulsions), and cause general “adultification” of children that leads to insufficient support of their developmental, psychosocial and academic needs. In clinical settings, implicit bias has been connected to misdiagnosis, improper intervention use, inaccurate prognosis and underutilization of counseling services.

Thus, implicit bias can easily enter our work as counselors, affecting how we assess and intervene with clients, which has short- and long-term effects on clients’ psychological, social, academic and career outcomes, to name a few.

I challenge emerging and seasoned counselors to reflect on their initial impressions of a client and where those impressions may originate. In addition, I encourage them to constantly seek information that may disconfirm those initial impressions. Professional development through ACA and consulting with peers invested in multicultural and social justice competency are invaluable supports for continued professional growth for addressing implicit bias.

What advice would you give to new counselors who may have doubts about their ability to accurately assess clients? 

Assessment can be a scary verb! I encourage counselors to remember that assessment has several flexible procedures and practices that can include qualitative or quantitative features. Every counselor, whether emerging or seasoned, can learn new strategies for engaging in effective assessment.

Being able to effectively assess clients is part of your journey as a developing counselor. We are trained to be engaged with clients through foundational helping skills, such as active listening, conveying authenticity, unconditional positive regard and empathy. I recommend that counselors rely on these skills to develop a therapeutic alliance with clients. As the alliance is strengthened, the likelihood that clients will disclose clinically relevant information and gain self-awareness of their presenting concerns and strengths can advance the assessment process. In turn, the assessment process can strengthen the therapeutic alliance, but without establishing an initial counseling relationship, effective assessment cannot occur.

Throughout the book, I provide several tip sheets to support counselors as they consider a variety of assessment approaches as well as strategies to effectively implement those approaches. The book begins with foundational information about assessment and the initial counseling and assessment phase and then transitions to crisis and trauma assessment and assessment procedures and practices for more focused mental health, addictions, cognitive, academic, career, personality and interpersonal concerns.

How can counselors communicate clinical assessment results with clients?

Although communicating assessment findings is usually considered the last phase of the assessment process, effective communication starts at the beginning of counseling. I recommend that counselors discuss with their clients why various assessment approaches are selected, what uses the various approaches have, what their strengths and limitations are, what clients can expect in terms of how these approaches will be introduced and administered during counseling, and how various findings and scores are interpreted and what potential implications those have for the client. If counselors have done a good job of navigating their clients through these assessment process steps, communicating assessment findings will have a greater benefit to their clients.


Assessment in Counseling, seventh edition, book cover


Order Assessment in Counseling: Procedures and Practices (seventh edition) from the ACA Store.




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.

Conceptualizing and assessing race-based traumatic stress

By Portia Allie-Turco July 6, 2023

A silhouette profile group of men and women of diverse cultures


Counselors have a responsibility to promote and provide equitable care and treatment as outlined in the ACA Advocacy Competencies and the Multicultural and Social Justice Counseling Competencies. To do so, counselors require awareness, knowledge and skills to work effectively with Black American clients. Clinicians seeking to treat Black American clients must understand that racial trauma is deeply rooted in historical, generational and ongoing systemic oppression and has a pervasive impact on the well-being of Black individuals and communities. The toll of racism is implicated in health and mental health disparities that can be addressed only through knowledge, awareness and a commitment to culturally responsive care. Culturally competent counseling requires specialized conceptualization, assessment and treatment of racial trauma.

A foundational understanding is that racism is embedded in all aspects of daily life and is a common and frequent experience for Black Americans. Racial inequity has profound economic, health and mental health impacts. Racial disparities contribute to unequal access to employment, education, housing and other material resources. Black families are more likely to live in dangerous neighborhoods and areas of concentrated poverty, have limited employment and poor access to quality health care, and experience food deserts, all of which exacerbate the effects of poverty and impede access to opportunity. Racism contributes to mental health issues such as anxiety, depression and posttraumatic stress. Racism is implicated in the phenomenon of weathering — a trauma response related to repeated exposure to chronic stress and adversity — resulting in myriad chronic health issues including hypertension, obesity, heart disease and early death.

The effects of racism extend to the counseling realm. Historically, racial trauma in Black American slaves was attributed to mental health conditions not believed to exist in other people. In 1851, Dr. Samuel Cartwright, who had apprenticed under Dr. Benjamin Rush, the “father of American psychiatry,” diagnosed two slave disorders he labeled “drapetomania” and “dysaesthesia aethiopica” (or “rascality”). Supposedly, drapetomania caused slaves to escape plantations; rascality was understood as an inherent trait of laziness and carelessness. Unfortunately, the idea of rascality continues to permeate views of Black Americans in relation to poor work ethic and criminality. The recommended treatment for both drapetomania and dysaesthesia aethiopica was physical torture. Today, these false diagnoses are associated with justifying police brutality and the harsh treatment of Black Americans facing legal authorities.

In counseling, Black Americans face an increased risk of retraumatization because of inappropriate assessment, misdiagnosis and poor treatment. Given this reality, and the resulting cultural mistrust of health care professionals, it is not surprising that rates of unilateral termination in counseling are much higher among Black American clients.

Conceptualizing historical trauma and slavery’s lasting effects

Historical racial trauma reflects the unresolved collective grief and cultural wounding that are passed down generationally. The field of epigenetics highlights that negative environmental conditions and stressors affect human beings down to the cellular level. For Black Americans, the racial trauma of slavery underpins a soul injury of unresolved grief that affects the whole being. In this context, the social-cultural wound is a collective experience of an internalized racial injury so pervasive that it impacts Black American culture in distinct racialized ways.

Anti-Black racism is rooted in the belief that people of darker skin tones are uncivilized, savage and prone to violence, regardless of how much status, achievement and standing a Black person may attain. This manifests in the phenomenon of colorism — the preference for lighter skin tone and Eurocentric features. Counselors need to know that colorism affects all aspects of a Black person’s life and influences their life chances, both within and outside of the Black American community. Black Americans face greater likelihood of poverty, more restricted access to education, and higher rates of imprisonment, underemployment and health inequity the further removed they are from the white ideal.

Posttraumatic slave syndrome (PTSS) is a theory of historical trauma that highlights the multifaceted impact of the violence of slavery, institutionalized segregation and oppression, and ongoing struggles for racial justice on the lives of Black Americans who are descendants of enslaved Africans. Counselors need to know the theory of PTSS, which was developed by researcher and educator Joy DeGruy-Leary to describe the survival strategies that were necessary for enduring the hostile conditions of slavery. PTSS accounts for both negative responses and positive adaptations and can explain some of the behavioral patterns of present-day Black Americans.

Controlling images and stereotypes

When Black American clients come to therapy, counselors should be aware of the controlling images and racial stereotypes these clients face.

The labeling starts early. In school, Black children are disciplined at higher rates than other children, with severe consequences that can include out-of-school suspensions, law enforcement involvement and, ultimately, even imprisonment for some Black children. Black boys are disciplined for being too “aggressive.” Black girls are disciplined for being “too loud” or dressing in a sexually provocative way. This reflects “adultification bias,” wherein school authorities hold Black girls to excruciatingly high standards because the girls are perceived to be more developed than they actually are. These responses stem from broader toxic stereotypes against Black Americans, deriving from slavery.

Controlling images underlie many of the mental health and stress-related concerns among Black women. One controlling image, the “Jezebel,” originated during slavery to justify the raping of Black women by white slave owners. It continues to have repercussions today in the increased risk of violent sexual assault against Black women due to the perception that they possess voracious sexual appetites and welcome aggression. The media also exploits the Jezebel trope and reinforces it in music videos, social media, television and movies, where Black women are often hypersexualized projections.

When counselors buy into the Jezebel myth, they risk misdiagnosing and mistreating sexually related concerns in therapy. Therefore, it is important to explore healthy sexual identity development and to challenge traumatic internalization of this controlling image. To further support and advocate for Black clients effectively, counselors need to be aware of these controlling images that discourage women from reporting sexual crimes and make it less likely they will be believed or find justice in court.

Another trope is the “Angry Black Woman.” This is routinely applied to Black women who are assertive and stand up in defiance of expectations of being demure and submissive. When they challenge injustice, they are labeled as domineering, masculine and emasculating. This combines racialized and gendered oppression and encourages the self-silencing of Black American women.

In response to these damaging stereotypes, Black American culture sought to reclaim the dignity of Black femininity. This was done in part by cultivating virtues of a Black matriarch who embodied strength, self-reliance, care of others and emotional containment while being a pillar of the community. In internalizing this “Strong Black Woman” schema, however, Black women are under enormous pressure to achieve excellence, block their emotions and care for others to the exclusion of their own needs. If counselors are unaware of this schema, they may not recognize the self-silencing, emotional dysregulation and fatigue that are the result of an endless demand on Black women for strength and voiceless endurance. Counselors should know that Black women who internalize this schema are most at risk for pain-numbing behaviors such as binge eating disorder, which is not about image or dieting, but rather an emotional regulation strategy.

Microaggressions and racial trauma in daily life

Psychiatrist and Harvard University professor Chester M. Pierce first proposed the term “racial microaggressions” to describe brief, commonplace verbal or behavioral racial slights, whether intentional or unintentional, that communicate hostile, derogatory or negative insults toward Black Americans. Microaggressions are often veiled and ambiguous; for example, complimenting a Black person about how well-spoken they are. The implication is that the listener is surprised because they did not expect the Black person to be articulate.

The subtle nature of microaggressions makes them especially frustrating for victims, who may be unsure of the intention behind the slight and unclear about whether or how to respond. This distress is damaging to a person’s well-being, especially when accumulated over time. Microaggressions result in increased stress, anxiety, depression and other trauma-related conditions. They can also lead to anger, voicelessness, internalized self-devaluation and an assaulted sense of self. 

Race-based traumatic stress

Experiences with discrimination and oppression can result in race-based traumatic stress (RBTS), a term coined by researcher Robert Carter and colleagues to describe the significant stress Black Americans experience because of cultural, individual and institutional encounters with racism. Much like posttraumatic stress disorder (PTSD), RBTS carries psychological and physiological effects such as avoidance, hypervigilance, flashbacks, nightmares and somatic expressions (e.g., headaches, stomachaches, heart palpitations). At the same time, racial trauma differs from PTSD in significant ways. For instance, racial trauma involves ongoing cumulative injuries due to exposure, both direct (such as physical assault) and indirect (such as vicarious injury when other Black people are racially harmed or when witnessing racist incidents in person or in the media).

RBTS also includes reexposure to race-based stressors. Criteria include exposure to a racist event that is experienced as painful and uncontrollable. The traumatic reaction of avoidance, intrusion or arousal can manifest in several ways, including emotionally, cognitively, behaviorally and physiologically. Unfortunately, most of these wounds are easily overlooked if counselors do not understand race-based trauma symptomatology. Black American clients may need help in understanding and managing their strong reactions to these events. It is incumbent on counselors to have this awareness because Black American clients may not know that these exposures are considered traumatic.

The fact that racism is a stressor that can harm or injure its targets is still not recognized as an official diagnosis in the most recent iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). This decreases the chances that counselors can identify, assess and treat RBTS, even though researchers have reported higher rates of traumatic experiences among Black Americans when compared with the general population.

Although the current diagnostic criteria for PTSD in the DSM-5-TR is more expansive with respect to trauma generally, it does not account for the symptoms of RBTS due to its limiting of the types of experiences that lead to trauma. For instance, Criterion A specifies “exposure to actual or threatened death, serious injury or sexual violence” as the main diagnostic criteria, even though other types of stressful experiences, such as racism, have been linked to negative mental health outcomes.

Criterion A also contains a specific notification, under Criterion A4, that explicitly states “experiencing repeated or extreme exposure to aversive details of the traumatic event(s) does not apply to exposure through electronic media, television, movies or pictures, unless this exposure is work-related.” This is concerning because advancements in technology and the ubiquitous reach of media have increased the exposure of Black Americans to heightened images of racial injustice and trauma, such as the gruesome images, in real time, of the murder of George Floyd.

Similarly, newer forms of hate crimes have emerged in social media networks as a convenient means of transmitting hate. All of this can have the effect of retriggering and retraumatizing previous racialized experiences. Black American clients might present to counseling with trauma stirred up by these media exposures to racism, but it may not be apparent because of the everyday nature of these incidences. In addition, diagnosis is difficult because of the electronic media exclusion note in Criterion A4.

The current definition of PTSD in the DSM-5-TR is problematic. It contributes to potential misdiagnosis and the pathologizing of racial stress symptoms, and it limits the ability of Black American clients to receive adequate racial trauma treatment. Additionally, without an official diagnosis, health care insurance coverage and reimbursement can be restricted.

RBTS assessment measures

Despite the limitations of the DSM-5-TR diagnostic criteria, counselors can still offer an appropriate assessment of RBTS, if they have the necessary knowledge and awareness and the proper tools. Experts in the racial trauma field have developed several scientifically validated instruments that accurately assess trauma symptomatology. Counselors can choose any of these instruments during a scheduled intake or following a session when a client presents with symptoms that may be indicative of racial trauma. These tools can help counselors assess Black American clients and develop treatment strategies for healing their traumatic experiences.

  • The University of Connecticut Racial/Ethnic Stress & Trauma Scale (UnRESTS) uses an interview format to facilitate communication regarding clients’ experiences with racism. UnRESTS uses a two-column format: one column with instructions for the counselor to prepare the interview and the other column describing questions to ask the client. This measure is helpful for counselors who are inexperienced in identifying racial trauma or those who are hesitant to broach racially charged topics in counseling. It provides clinicians with a structure to conduct the interview, starting with identifying racial or ethnic identity development and moving through experiences of covert and overt racism, including vicarious racism. This provides counselors with the confidence that they have elicited the greatest input from their clients on these issues and can make a treatment plan based on this comprehensive review.
  • The Race-Based Traumatic Stress Symptom Scale (RBTSSS) evaluates a client’s exposure to racist experiences and the symptoms that can result, including emotional and physiological reactivity. The measure includes 52 items in seven categories that explore self-esteem, physical reactions, anger, avoidance, depression, intrusion and hypervigilance or arousal, all associated with racial trauma. When using the RBTSSS, the clinician begins with open-ended questions to obtain information from the client about racist experiences. This is followed by closed-ended questions about the client’s reactions. A clinician can assist in administering this assessment, or it can be administered as a self-report measure.
  • The General Ethnic Discrimination Scale (GEDS) is an instrument specially designed for measuring clients’ frequency of exposure to racism. It is appropriate to use with most ethnic groups affected by racial trauma. GEDS consists of 18 self-reported items that measure the client’s personal perception of racial discrimination. This tool is similarly structured to other existing stress inventories currently in use. Because this is a self-reporting tool, instructions have been simplified for participants whose first language is not English. It is also specifically useful when faced with time constraints because it is a relatively quick measure for assessing racial trauma.
  • The Racial Microaggressions Scale (RMAS) is a tool measuring racial slights and the resulting distress of microaggressions. It specifically explores six types of microaggressions using a 32-item questionnaire in a Likert scale format. The distress subscales include criminality distress, low achieving/undesirable culture distress, sexualization distress, invisibility distress, foreigner distress and environmental distress. Counselors might choose this assessment when Black American clients report experiencing insults and invalidations that undermine their sense of self.

Because racial trauma is so deeply rooted in historical and generational oppression going back to slavery, Black Americans continue to experience the devastating toll. Counselors who work with Black Americans must understand the conceptualization of this experience and be competent in evaluating its impact on their clients.


Learn how to treat race-based traumatic stress in July’s Knowledge Share article “Treatment strategies for race-based traumatic stress.”


headshot of Portia Allie-Turco

Portia Allie-Turco is an assistant professor, clinic director and program coordinator in the Counselor Education Department at the State University of New York at Plattsburgh. She is also a licensed mental health counselor who specializes in healing racial, generational and complex trauma. Contact her at p.allieturco@gmail.com.

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