Tag Archives: youth

Helping youth who self-harm

By Bethany Bray January 10, 2023

A teenager wearing a mask sits on stairs with her chin and hands resting on her knees. The teenager is looking straight head into the camera. A bookbag sits beside the teenager.

Ground Picture/Shutterstock.com

Self-harm behaviors in American youth rose sharply during the peak of the COVID-19 pandemic and continue to be a concern among counselors who work with children and adolescents.

In early 2021, FAIR Health completed an in-depth analysis of insurance claim records to compare changes between 2019 and 2020. The New York City-based nonprofit found the mental health claims for individuals between the ages of 13 and 18 doubled between March and April 2019 and the same months one year later.

That same age group saw a startling increase — nearly 100% — in the number of insurance claims for medical care received for intentional self-harm between April 2019 to April 2020. And the Northeastern United States (Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont) saw the highest spike in claims for treatment of injuries in teenagers from intentional self-harm — a 333.93% increase — between August 2019 and August 2020.

This data tracks with what many counselors are seeing in their own caseloads: An increase in young clients who turn to self-harm to cope with the stress and upheaval that came — and continues to come — with the COVID-19 pandemic.

There is a strong correlation between social isolation and self-harm, notes Deanna Dopplick, a licensed professional counselor (LPC) at S.A.F.E. (Self Abuse Finally Ends) Alternatives, an outpatient program that specializes in treatment for nonsuicidal self-injury (NSSI) in St. Louis. As hard as it was for children and adolescents to have decreased connection with peers while schools were closed during the peak of the pandemic, it’s been equally challenging for them to return and reintegrate to the social dynamics of in-person school, she says.

Dopplick, an American Counseling Association member, is among the many practitioners who are seeing an uptick in client referrals for self-harm among children and adolescents. Her organization has “struggled to keep up” with the need for services, she says, and unfortunately, many prospective clients sometimes end up on a waiting list. In addition to new clients, Dopplick says she’s also seen an increase in relapses among clients who have returned to self-harm behaviors to cope after making progress in therapy previously.

As more counselors see youth who self-harm on their caseloads, Dopplick urges practitioners to focus on empathizing with these clients and fostering a trusting therapeutic relationship. The worst thing a practitioner can do, she says, is to panic or act fearful when a client discloses the behavior or dismiss it as attention-seeking.

“I have seen clients that have been in therapy for months or even years [before coming to SAFE], and the behavior has been so protected and shameful that they haven’t disclosed it. There is a stigma that self-injury is weird or different or ‘crazy.’ It’s not something that’s easy to open up about,” says Dopplick, who provides individual and group counseling for clients 12 and older. “We [counselors] need to make sure we’re meeting the client where they’re at, humanizing them and validating their experience. … It [self-harm] is so much more common than people think, and it doesn’t make [the client] scary or different. Empathy goes a long, long way with these clients.”

A way to cope

Michael Visconti is a licensed mental health counselor who treats children and adolescents in private practice in Boston. He estimates that one-quarter of his caseload at any time is exhibiting self-harm behaviors — a proportion that rose to roughly 50% during the peak of the pandemic. Many of these clients are referrals for self-harm from a local pediatric medical office.

The youngest client Visconti has counseled for self-harm behavior (in the form of intentional head banging) was six years old, but he finds it’s most common in younger teenagers, ages 12 to 15, he says.

Like Dopplick, Visconti emphasizes that there is a “direct correlation” between social isolation, feelings of hopelessness and self-harm behaviors in youth. “The more isolated an individual is, the less they feel they can reach out to others and express that emotion, so they turn inward,” Visconti explains. “Most often, it’s a maladaptive form of coping.”

While the intense isolation that occurred during the peak of the pandemic has lessened, all the same stressors that youth experienced before the pandemic (such as abuse, neglect or trauma at home, negative body image, social pressures and negative messaging on social media) remain, he notes.

In Visconti’s experience, the reasons that drive youth to self-harm often fall into a few common categories:

  • Managing emotions: When feelings are strong and uncomfortable, adolescents and young clients sometimes find it easier to experience physical pain rather than emotional distress. Self-harm offers an immediate and effective means of emotion regulation in the short term. Visconti says that in his experience, this is the most common pathway to self-harm.
  • Communicating: Some individuals make use of self-harm to outwardly display their emotional pain because they don’t have the means or opportunity to put it into words. This can be especially common among youth who live in invalidating family and home environments, Visconti says.
  • Punishment: Young clients sometimes turn to self-harm to punish themselves and “confirm” and internalize the negative narrative they have about themselves, Visconti says. These clients often believe that they are the problem and reason for their unhappiness, and self-harm is a way to reinforce these feelings. This is common among youth with poor self-esteem and/or a trauma history, he adds. Dopplick also finds that young clients who self-harm often struggle with intrusive thoughts that are intensely negative, such as “I am bad,” “There is something wrong with me” or “I am a disappointment,” so she spends a lot of time focusing on redirecting self-talk with clients at her program.
  • Seeking control: Some young clients turn to self-injury as a means to exert control in their life, albeit in a painful way. It can be a maladaptive way to find autonomy, Visconti explains. This was the especially the case when many youths felt that the “fundamentals of their life had been stripped” away during the pandemic, such as the routine of the school day, social activities, extracurricular activities and other things they enjoyed.

Asking the right questions

The crux of what defines NSSI is the intent behind the behavior, Visconti explains. Self-harm can be an impulsive phenomenon as well as something that is very deliberate, planned and well thought out. Visconti says that it’s not uncommon for him to see young clients who have created a self-harm “kit” for themselves, complete with harming tools as well as items to disinfect and treat wounds afterward.

When assessing for self-harm, counselors should not hesitate to ask clients directly about whether an injury was deliberate to determine intent, Visconti says. He often uses questions such as “Was that [injury] purposeful?” or “Did you place yourself in that setting with the hope that it harmed you?”

That second question can help uncover behaviors that are beyond the common ones that counselors may think of, such as cutting or burning. For example, Visconti once had a young client who slept on a mattress that had a metal spring poking out of it, and he purposely didn’t tell the adults in his life about it because he hoped that it would cut and injure him while he was in bed.

Asking questions about intent can also help uncover behaviors that a client has kept hidden or that escape the notice of peers or adults in a client’s life.

Dopplick has also seen self-injury behaviors that are outside of what a counselor may expect. This includes keeping a (non-self-inflicted) wound from healing, hitting or biting oneself, inserting objects under the skin, ingesting things that the client knows are toxic or dangerous (such as glass or household cleaners), head banging, hair pulling, picking of skin or nails and other behaviors.

In sessions, asking clients questions to determine the frequency and severity of self-harm impulses and actions is vital to understand the context of their behavior and level of risk, Dopplick says. For example, a client who has self-injured twice by a single method (i.e., rubbing themselves with an eraser to the point of burning) will need a different response than an individual who has injured themselves 100 times or uses multiple methods (e.g., cutting with a razor blade, punching walls).

Understanding the full context of a client’s NSSI can help a counselor identify the reasons why they engage in the behavior and, ultimately, personalize and tailor treatment to meet their needs. Dopplick encourages counselors to ask clients a range of questions, including:

  • Have they ever received medical attention for NSSI or needed attention but didn’t seek it?
  • What tools are they using to injure themselves? Do they have access to these tools?
  • How often are they engaging in self-injury?
  • Are their harming behaviors usually impulsive or preplanned?
  • Does anyone else, such as a parent or a friend, know that they’re self-injuring?

“Having the impulse to injure is different than following through with action,” Dopplick adds. “They may have impulses every day but may only injure once per week. It’s something to ask about: How are they managing their impulses?”

She recommends counselors ask clients to keep a log to track situations when they felt the urge to self-harm or engaged in self-harm, which she says can be helpful in therapy because it can shed light — both for the client and the clinician — on patterns. Dopplick encourages clients to record what they were doing and feeling before, during and after an urge to self-injure to help identify triggers.

Although NSSI is distinct from suicidality, the counselors interviewed for this article note that it’s important to assess clients who self-harm for suicidal intent because the two issues can sometimes overlap.

Visconti uses the Columbia-Suicide Severity Rating Scale and recommends it as a helpful way to screen both for suicidality and self-injury and parse out the intent and severity of a client’s behavior. The tool’s questions can help determine how chronic a client’s behavior and feelings are, he explains, and it can be easily used with many different client populations and treatment settings.

Discussing self-injury with a young client can be uncomfortable or worry-inducing for a clinician, Dopplick and Visconti admit. However, it’s vitally important for counselors to complete a thorough assessment to determine a client’s level of risk without becoming panicked and jumping to crisis response, such as talking about hospitalization.

“If you [the counselor] seem scared or overwhelmed or go straight into crisis mode, you won’t get all the information you need from the client,” Dopplick stresses. And “that will make them very hesitant to disclose self-injury again.”

She encourages counselors to keep an open mind when asking clients about their self-harm behaviors. Making assumptions about the factors that contribute or the reasons why they are engaging in NSSI “is the best way to shut down the conversation,” Dopplick adds.

Instead, “see the client as the expert on themselves and their behavior. Do not criticize, minimize [the behavior], come off in a punitive way or assume they’re doing it for attention or because their friends are doing it,” she stresses. “Really put the client in the driver’s seat instead of coming at them with assumptions.”

Finding healthy ways to cope

At its core, NSSI indicates that a client has unmet needs, Dopplick says. A counselor’s role then is to help the client identify and understand those needs and find ways to meet them without turning to self-harm.

“No one self-injures for no reason; there’s always an underlying reason, a function,” she notes. “For most clients, it [self-harm] is something that they’re hiding, something just for them, something that ‘helps’ them.”

Dopplick says that the counseling groups she leads for self-injury spend the majority of the time talking about the context and circumstances surrounding their self-harm, rather than the actual behavior. For young clients, this often includes the pressures their parents put on them or stress related to school or social relationships.

“We talk about the why and how more than the what,” Dopplick says. “The self-injury is not the actual problem; it’s what’s underneath it. All the underlying stuff — the why — is the problem, and [counselors] can miss the boat if [they] don’t explore it.”

Paige Santmyer, an LPC who works with teens and adults at a Christian counseling practice in the Atlanta area, agrees that helping clients identify what triggers their urge to self-harm is an important first step, followed by creating a plan to replace the behavior with healthier options. It also helps to identify the perceived “reward” they seek in self-harm, she says, to tailor a client’s treatment plan and coping mechanisms.

For example, if a young client struggles with feeling numb and turns to cutting themselves to feel something, Santmyer says she would teach the client mindfulness and guided imagery techniques that can help them connect to how they’re feeling. Or, depending on the client, they might respond to something creative such as using virtual reality to “go” hiking or zip lining to redirect and energize themselves, she suggests.

Young clients will need activities and techniques at the ready to replace the urge to self-harm; planning ahead is key. Santmyer brainstorms with clients to identify ways they can seek connection and soothe themselves when needed, such as doodling or drawing or talking to an accountability partner.

She also finds it helpful to have young clients create a “distraction box” filled with special or favorite items that can help to self-soothe and take their minds off the urge to self-harm. These items can include art, knitting or crochet supplies, essential oils, a favorite lotion, coloring or puzzle books, pictures of loved ones, an object with beads for counting or a kaleidoscope to look through. (For more on creating self-soothing kits with clients, read the Counseling Today online exclusive “Regulating the autonomic nervous system via sensory stimulation.”)

Similarly, Visconti says he focuses on helping young clients who self-harm find ways to redirect themselves away from the urge to injure. He gives clients a worksheet with 100+ ideas from Matthew McKay, Jeffrey Wood and Jeffery Brantley’s The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation & Distress Tolerance to spark ideas and keep for future reference. Depending on the client’s age and needs, activities could include playing video games, visiting a friend, eating their favorite flavor of ice cream, writing a song, using an app to learn a new language, getting a haircut or painting their nails.

Managing distressing emotions

The counselors interviewed for this article agree that while clinicians need to tailor their work to fit their clients’ individual needs, many young clients who self-harm will need some combination of treatment that challenges negative self-talk and strengthens distress tolerance and emotion recognition and regulation.

Santmyer says that it’s common for young clients who struggle with NSSI to be disconnected from and confused about their emotions.

She focuses on emotion recognition with clients by asking them to think about where they feel strong emotions in their body and prompting them to talk about what it feels like and how they usually respond to those sensations. She also finds cognitive behavior therapy (CBT) helpful to guide clients to explore, challenge and reframe the fears and negative core beliefs that drive feelings such as worthlessness or perfectionism that trigger an urge to self-injure.

“Helping them understand and name the emotion they are feeling helps clients feel more in control of themselves instead of feeling compelled to manage the sensation itself through self-injury. Counselors can also use CBT to build insight into how emotions are giving them messages, how they can interpret them in positive or negative ways, and how those interpretations lead them toward or away from self-injury,” explains Santmyer, an ACA member. “Ultimately, clients will need to understand how they are perpetuating their self-injury cycles and practice changing their negative thoughts to change their self-harming choices into more thoughtful and healthy responses.”

Santmyer and Visconti also noted that dialectical behavior therapy (DBT) can be especially helpful to use with young clients who self-harm because of its focus on emotion regulation and distress tolerance. (Santmyer and Visconti are not certified in DBT but have studied it and draw from the method in their work with clients.)

DBT is a good fit for this client population because it’s practical and effective in a short amount of time and it teaches much-needed skills and coping mechanisms to manage stress and tolerate uncomfortable feelings, Visconti notes. In fact, he says he’s seen DBT techniques spark growth and healing in self-harm clients right away because of the skill-building component.

However, DBT is most helpful for clients who self-harm as an emotional outlet, rather than those who use the behaviors to communicate or exhibit their emotional pain, he adds.

Santmyer finds that the ACCEPTS skill from DBT is particularly helpful to strengthen clients’ ability to overcome distressing emotions and situations without turning to self-harm. This tool guides clients to think about or engage in:

  • Activities: Do something that requires thought and focus, such as writing in a journal, to shift their attention away from distressing emotions.
  • Contributing: Do something that involves focusing on other people (e.g., sending a card, asking a loved one about their day, doing volunteer work).
  • Comparisons: Put their situation in perspective by comparing it to something more painful or challenging, including thinking of a time when they were in greater distress and got through it.
  • Emotions: Find a way to disrupt the emotion they are feeling (e.g., angry, sad) and replace it with a different or opposite emotion (e.g., going for a walk to calm oneself, watching a happy movie).
  • Pushing away: Use a technique such as guided imagery to block painful feelings from their mind and delay the urge to self-harm.
  • Thoughts: Use a strategy to shift one’s thoughts to something neutral (e.g., counting backwards, reciting song lyrics, naming objects around them that start with a certain letter of the alphabet).
  • Sensations: Engage in activities that trigger safe sensations that distract them from distressing emotions (e.g., eating something spicy, feeling the water on their body during a shower).

Trust and validation

Getting to know the client and tailoring treatment to their individual needs must take priority when counseling youth who struggle with NSSI, Dopplick says. She suggests that practitioners first find ways to connect with clients — particularly those who have been referred to counseling specifically for NSSI — and talk about topics other than self-injury to forge a trusting relationship.

Believing the client and validating their experience and pain should be the counselor’s No. 1 priority, she stresses. Only then can a counselor begin to identify and delve into the reasons underneath their self-injury.

“Often [these clients] feel that no one understands or validates their pain, and they are compelled to continue self-harming as a way to express in their body what they feel they cannot express verbally,” Santmyer says. “The validation and compassion of the therapist will bring the safety that young clients need to explore the drivers of self-harm.”

Dopplick finds that she’s sometimes the first adult to tell a young client that she understands why they are distressed to the point of needing to self-harm or to emphasize that they’re not weird or “crazy” for engaging in NSSI. After validating the client’s experience, she explains that she can help them find other ways to cope.

It’s vital for counselors to keep an open mind and accepting demeanor with these clients, Dopplick stresses. “There’s a huge difference between expressing your concern in a caring way, rather than asking 1,000 questions and focusing on” a client’s self-harm behaviors, she says. “It’s important to approach it with curiosity. … They know themselves and know what this behavior does for them; you just have to help them figure that out, and then build off of that to get more information.”

When working with young clients who self-harm, Visconti says he makes sure to acknowledge how hard it is to disclose and discuss such a painful and deeply personal topic. He thanks them for trusting him with such vulnerable information and feelings. “I empathize [with clients], commiserate and then try and bring about a sense of hope and preservation,” he adds.

The most important technique a counselor can use with these clients is the therapeutic relationship itself, Visconti says.

He admits that young clients who engage in self-harm can be challenging, not only because it’s an uncomfortable topic to address but also because they often have multiple presenting concerns or mental health challenges.

However, he pushes back against the misnomer that talking about self-harm in therapy can increase the behavior, retraumatize or cause emotional harm for a client. Counseling involves delving into many different types of painful topics, he says, and the key is for practitioners to handle it with openness and warmth.

“The long-term benefits greatly outweigh that distress,” Visconti emphasizes. “It’s so crucial to the betterment of their client, and you’re not going to increase the likelihood [of NSSI] by talking about it — it doesn’t work like that.”

Challenges that can co-occur with nonsuicidal self-injury

Depression and anxiety are the most common diagnoses that can co-occur in young clients who engage in nonsuicidal self-injury (NSSI). However, there are many other challenges that individuals may struggle with simultaneously.

There is a high correlation between NSSI and eating disorders, as well as clients who have experienced trauma, particularly sexual trauma, as self-harm can be a way for these individuals to seek control, disconnect or cope with painful feelings, trauma flashbacks or the stress of continuing to live in an abusive environment.

It also can co-occur with obsessive-compulsive disorder in clients who use self-injury to satisfy urges for repetitive behaviors to manage or communicate distress. This can also be the case for individuals with autism.

“It’s very effective to disconnect: To disconnect with their brain, with their body and overwhelming feelings, and this [self-injury] gets it to stop. But that’s also one thing that makes it hard to stop doing,” says Deanna Dopplick, a licensed professional counselor at S.A.F.E. (Self Abuse Finally Ends) Alternatives, an outpatient program that specializes in treatment for NSSI in St. Louis. “A lot of people think of self-injury as this impulsive thing, and it can be, but it also can be very obsessive. If they [a young client] can’t manage their stress at school, they may be thinking all day about injuring once they get home.”

The relief and other satisfactions that an individual seeks from self-harm lessen over time, which sometimes causes individuals to increase the self-harm behaviors and, eventually, turn to other risky behaviors, such as sexual promiscuity, restrictive eating or using substances, to seek similar feelings of reward or relief. So counselors who work with clients who disclose self-injury behaviors (or a past history of NSSI) should also screen for substance use, suicidal ideation, eating disorders, behavioral addictions and other high-risk or destructive behaviors.

This information came from an interview with Deanna Dopplick, a licensed professional counselor at S.A.F.E. (Self Abuse Finally Ends) Alternatives (selfinjury.com).

Supporting parents of young clients who self-injure

Counselors who work with children or adolescents who self-injure are in a position to offer support to adults in the client’s life who are misunderstanding or anxious and upset about the child’s behavior.

Understandably, parents often panic and experience intense worry when they find out their child is self-harming, says Deanna Dopplick, a licensed professional counselor at S.A.F.E. (Self Abuse Finally Ends) Alternatives, an outpatient program that specializes in treatment for nonsuicidal self-injury in St. Louis. Often, parents’ first response is to enact punishment, such as taking the child’s cellphone away to cut off contact with friends or locking up all the sharp objects in the home.

However, this won’t stop the child’s self-harm behavior — it can actually increase it, Dopplick says. A punitive response from the adults in a client’s life will only cause the child or adolescent to feel even more shame about their self-harm, and it can lead them to engage in harming behaviors that are more hidden and secretive. This includes injuring themselves in ways that won’t leave a mark or on parts of the body that are usually covered by clothing.

It’s also not helpful for parents to reward a child for going a length of time without injuring themselves, she adds. Counselors can offer psychoeducation to parents on why the punishment-reward cycle is not effective in situations of self-harm, and they can provide healthier alternatives.

“We have to remember that it [self-harm] is a coping mechanism. It’s not a healthy one, but it does not mean that the child is ‘bad,’” seeking attention or acting out, Dopplick stresses.

She finds that the book Healing Self-Injury: A Compassionate Guide for Parents and Other Loved Ones by Janis Whitlock and Elizabeth Lloyd-Richardson is a helpful resource to recommend to parents. The book offers guidance on ways parents can talk to their child about self-harm and support them in a healthy way. (Whitlock, one of the co-authors, is the director of the Self-Injury & Recovery Resources research program at Cornell University; Dopplick notes that Whitlock’s entire body of research can be helpful to counselor practitioners who want to learn more about the topic of self-harm.)

Parents often jump to the assumption that self-harm behaviors mean that their child is suicidal, says Michael Visconti, a licensed mental health counselor who treats children and adolescents in private practice in Boston. Research indicates that the majority of individuals who self-harm do not have suicidal thoughts, he notes.

So counselors can educate parents on the differences between suicidal ideation and self-injury and assure them that although self-harm behaviors are concerning, they don’t necessarily mean that their child wants to end their life, Visconti stresses.

Bethany Bray is a former senior writer and social media coordinator for Counseling Today.

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.

Supporting transgender and gender-expansive youth

By Cortny Stark July 29, 2022

Transgender and gender-expansive (TGE) children and youth continue to experience marginalization, as institutions across the United States institute new oppressive policies that challenge and, in many cases, altogether prevent access to gender-affirming health care. TGE children and youth include young people between ages 3 and 17 whose gender identity is different from the sex designated at birth; the label “transgender” implies alignment with the gender binary (e.g., “I was designated female at birth and am a transgender man”), whereas gender-expansive identities do not align with the gender binary (e.g., “I was designated female at birth and am nonbinary — meaning that I am not a girl or boy”).

The realities of living as a TGE child or youth in today’s social, legal, educational and health-related environments are harrowing. Every day, new policies and legislation are introduced regarding TGE youth’s rights to access medically necessary gender-affirming health care, present as their authentic self at school, participate in extracurricular programs and sports, and have their appropriate name and pronouns honored in educational spaces.

As the parent of an incredible 12-year-old TGE child, my tolerance for the headlines is waning. I wake up each morning and check the latest news, and suddenly, I feel anxiety rising in my chest. I feel breathless and sick to my stomach. I have to put down my device and find a comforting television show or familiar rerun to watch before continuing with my day.

But we can do something about it. As helping professionals, we have an ethical obligation to support members of this community, as well as their caregivers and loved ones, and to advocate for dissolution of oppressive policies and legislation.

The current crisis

Despite over a decade of research and clear medical guidance supporting the efficacy of affirming social and medical interventions, several state and local governments across the United States have initiated anti-TGE legislation. In April 2022 alone, more than 20 pieces of legislation targeting the rights of TGE persons were introduced across the country.

On April 20, the Florida Department of Health released guidance on the treatment of gender dysphoria for children and adolescents, which states: “social gender transition should not be a treatment option for children or adolescents” and “anyone under 18 should not be prescribed puberty blockers or hormone therapy.” Alabama enacted a similar prohibition on affirming health care, but with more severe consequences for providers who violate the ban. The Vulnerable Child Compassion and Protection Act, which took effect May 8, states that health providers who provide gender-affirming puberty blockers or hormones will be charged with a Class C felony. Sanctions for violating the ban could include 10 years in prison or $15,000 in fines.


Standards of practice from the American Academy of Pediatrics and World Professional Association for Transgender Health, however, continue to support social and medical transition as a necessary option for the health and well-being for many TGE youth.

Earlier this year, Texas Attorney General Ken Paxton issued an opinion stating that gender-affirming medical interventions, referred to as “elective sex changes,” are part of a “novel trend” and “constitute child abuse.” The fact that this opinion equates gender-affirming care with “child abuse” is of particular importance for helping professionals because this means credentialed providers are legally obligated to notify child protective services within 48 hours of learning that a minor is receiving gender-affirming medical care.

Many families and caregivers of TGE youth in Texas are now unable to access medically necessary gender-affirming interventions, such as puberty blockers and hormone replacement therapy. In addition, major TGE advocacy organizations are encouraging families and caregivers of TGE youth to maintain a “safe folder” — a collection of documentation that debunks the “affirming care is abuse” myth. The folder includes “carry letters,” which are documents written by licensed counselors, helping professionals and/or pediatricians who have worked with the youth. These letters contain the professional’s credentials, their relationship to the youth, a statement from the American Academy of Pediatrics supporting gender-affirming medical interventions as evidence-based and best practice, and an overview of the youth’s gender identity development process.

A call for advocacy

I share these current events not to stir your compassion but to make a request: Please act and advocate for TGE youth. You can pursue positive change in whatever realm you hold power, privilege or space. As a professional, I wear many hats, including assistant professor, mental health and substance use counselor, rehabilitation counselor, training facilitator and advocate. These professional roles provide a space for me to channel my anxieties and distress over these recent oppressive policies targeting TGE youth and work toward positive change.

For me, advocating for this population serves as a source of nourishment and a way to derive meaning from what feels like hopeless circumstances, and I hope that engaging in this work may do the same for my colleagues. Here are some ways helping professionals can better support the advocacy efforts for the TGE community:

  • Use a humanistic lens when working with TGE children and youth and recognize the client as the expert on their own experience.
  • Get to know the standards of care and research regarding evidence-based care with TGE youth. And make sure the research you consume and the information you share with others all come from prominent and reliable scholarly sources.
  • Elevate the voices of TGE youth. If you work with this population, know what prominent TGE community organizations provide safe and brave spaces for TGE youth, and be prepared to share this information with your clients. If you facilitate trainings or educational opportunities for responsive and competent practice with the TGE community, and you yourself are not a member of this community, use panels of TGE folx to share their experiences and expertise.
  • Inform people that gender-affirming social and medical interventions are medically necessary and are a key component of suicide prevention. According to a 2009 report by Caitlin Ryan, the director of the Family Acceptance Project, TGE children experiencing caregiver or family rejection are more than eight times as likely to have attempted suicide and nearly six times as likely to report high levels of depression than TGE youth who were not or only slightly rejected by their parents and caregivers. This report also found that TGE youth who were in accepting homes, with caregivers who supported social and/or medical affirming interventions, had rates of anxiety, depression, and suicidal ideation and attempts similar to their cisgender peers.
  • Advocate with and on behalf of these youth in their living environments, schools and greater communities; this may include educating others about the role of affirming health care in preventing suicide and improving TGE youth’s overall health and well-being, testifying against oppressive anti-TGE legislation, or supporting affirming legislation.
  • Honor the history of TGE communities by acknowledging the role of colonization and historical trauma in the erasure of histories of gender diversity. Recognize the systemic influence of adverse experiences in health care, schools, the legal system and other institutions on TGE individual’s ability to trust institutions. This history along with the major influential events in the lesbian, gay, bisexual, transgender and queer (LGBTQ+) rights movement are key to understanding the intergenerational trauma and resilience of members of TGE communities.
  • Keep learning! Developing one’s ability to provide culturally responsive care requires lifelong education and reflective practice. Sign up for workshops and continuing education regarding serving TGE individuals. And join consultation and supervision groups that focus on providing care to this population.
  • Connect and advocate. Connect with a local TGE advocacy organization and volunteer to support their efforts; if time does not allow for this level of engagement, consider donating to these causes to support their advocacy work.

As LGBTQ+ advocate, actress and film producer Laverne Cox once stated, “Each and every one of us has the capacity to be an oppressor. I want to encourage each and everyone of us to interrogate how we might be an oppressor and how we might be able to become liberators for ourselves and for each other.” At this point in history, it is critical that we as helping professionals identify how our actions contribute to the oppression of our TGE clients and do better. The health and well-being of an entire generation of TGE youth need helping professionals who are willing to use their power and privilege to elevate their voices and serve as liberators.



Cortny Stark

Cortny Stark (she/her/hers) is an assistant professor and the substance use and recovery counseling program coordinator in the Department of Counseling and Human Services at the University of Colorado, Colorado Springs. She is also a telehealth therapist with the Trauma Treatment Center and Research Facility, where she provides trauma reprocessing and integration, clinical services for substance use and process addictions, and support for transgender and gender-expansive youth. Her research focuses on LGBTQQIA+ issues in counseling, integrative approaches to trauma reprocessing and integration, and substance use and recovery.


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.

Responding to the youth mental health crisis in schools

By Bethany Bray July 25, 2022

Late last year, U.S. Surgeon General Vivek Murthy issued an advisory to call attention to what he described as a “youth mental health crisis.” Depression, suicidality and other mental health challenges have been on the rise among American youth in the past decade, but Murthy believes the stressors and isolation of the COVID-19 pandemic exacerbated an already alarming situation.

In a June interview with ABC News, Murthy acknowledged that the crisis is ongoing, saying, “Ultimately, we will know when we’ve reached the finish line when they’re [American youth] doing well and they tell us they’re doing well and when data tells us that as well.”

Murthy’s advisory called attention to a concerning situation that school-based counselors continue to witness firsthand. American students are experiencing an increasing severity and prevalence of mental health challenges that range from self-harm and disordered eating to underdeveloped social and emotional regulation skills.

Students are trying to learn among a multitude of storms. America continues to struggle with the ongoing dual crises of racial injustice and the lingering COVID-19 pandemic. And on top of that, divisive issues related to schools have been making news headlines lately, including laws created to target transgender youth, arguments about critical race theory and school curriculum, and despair and finger-pointing after the deadly school shooting in Uvalde, Texas, which claimed the lives of 19 elementary school students and two teachers. 

It all adds up and is affecting the day-to-day lives of children and families. 

With a problem so large, it’s going to take more than school-based counselors to reverse the concerning trends in youth mental health. School counselors are on the front lines of this storm, but they also need buy-in, support and collaboration from school administration and staff, parents, community mental health professionals and the community at large.

Distress in students

Jennifer Akins, a licensed professional counselor (LPC) and president of the Texas School Counselor Association, noted that schools across her state are seeing both increased prevalence and severity of depression, anxiety, self-harm, suicidality and eating disorders among students. This has prompted statewide agencies to collect and track data on student mental health, including self-harm, to inform interventions and programs to be deployed in the public schools, Akins says.

“These are not new issues for us, but the thing is the numbers are so much greater,” says Akins, the senior director of guidance and counseling for the McKinney, Texas, public schools. “A huge area of need right now is emotional regulation. They [students] are just not as skilled right now at managing strong feelings. … Students who are experiencing thoughts about self-harm are more often advancing those thoughts into action. They now have thoughts, plus a plan, plus action.”

Texas school counselors are also reporting an increase in self-harm in young students at the elementary level, Akins adds.

Akins is far from alone in what she is seeing. The school-based counselors interviewed for this article report similar rises in self-harm, depression and other mental health challenges among their student populations. Many of these issues were present before the pandemic, but the isolation and lack of social interaction the students experienced while learning remotely during the first years of the pandemic weakened students’ social skills and their ability to regulate their emotions and cope with distress. According to several of the school counselors interviewed for this article, students’ social media use is also a factor that often makes these issues worse.

Jessica Henry has been a high school counselor for 15 years in the Akron, Ohio, area, and she says she’s never seen so many students struggling with suicidal ideation, self-harm, depression, anxiety and panic attacks.

Students are experiencing a lack of resilience and continue to struggle to adjust to in-person school, and for some, this includes developing unhealthy coping mechanisms such as self-harm, Henry says. Small problems that could otherwise be overcome often spiral into “the end of the world” for students, adds Henry, a licensed school counselor in a seventh through 12th grade school in Ashland, Ohio.

For some students, home can be a tumultuous atmosphere and a source of stress, so school functions as a safe place, which they lost when schools switched to at-home learning during the pandemic, notes Henry, a licensed professional clinical counselor and supervisor.

Jessica Holt, an LPC and counselor at a middle school in metro Atlanta, has noticed that in addition to self-harm, depression and anxiety, interpersonal problems, such as bullying and conflict with peers, have become more prevalent recently. Her school has seen an increase in the number of students requesting one-on-one counseling on their own, as well as referrals from teachers and school staff for students who need someone to talk to. There has also been an increase of students who are struggling with sexuality or gender identity issues or who feel like they don’t fit in, she says.

Even though most schools have returned to in-person instruction, the effects of being out of the school environment continue to affect students’ mental health, particularly their self-esteem, social skills and anxiety, says Holt, a member of the American Counseling Association. They are still out of practice with navigating classroom dynamics and making friends.

In Holt’s experience, many parents overcompensated and became more involved in their children’s lessons while they were at home for virtual learning. Parents would log in during virtual learning and check their child’s grades, monitor their work and send messages to teachers. As a result, Holt has noticed that students are struggling with autonomy and self-esteem now that they have returned to in-person classes. Parents are more likely to be the one to message the school when a student is failing, she notes, rather than the student being proactive and asking to make up missed assignments or for extra help.

“Kids don’t have problem-solving skills because things have been done for them. They don’t know how to cope when they are in distress,” Holt says. “One thing that has come out of the pandemic is [problems with] accountability. Students are not taking responsibility because their parents have taken everything on. … That self-advocacy piece is not there for a lot of students.”

Early intervention

Derek Francis, manager of counseling services for the Minneapolis Public Schools, says that his district will be doubling the number of elementary school counselors this fall. Counseling staff at the elementary, middle and high school levels in Minneapolis have also been leading more small groups for students to focus on social-emotional learning, managing stress, anxiety and other mental health challenges.

Minneapolis students are struggling not only with self-esteem, peer conflict, anxiety and other mental health issues but also with discrimination and bias based on racial, sexual and other identities, including negative interactions on social media, says Francis, who co-authored a chapter on proactively addressing racial incidents in schools in the ACA-published book Antiracist Counseling in Schools and Communities. In response, Francis’ school district has enhanced counseling services (including small groups) and weaved mental health discussions with a cross-cultural focus into classroom lessons across grade levels. It’s powerful when students hear that their peers are feeling some of the same anxiety and distress they are experiencing and are able to talk about it openly, says Francis, who works in the Minneapolis Public Schools’ Department of College and Career Readiness.

The Minneapolis schools are also taking an early intervention approach to mental health. Recent years have shown that elementary students can benefit from learning coping skills that help them regulate and calm themselves and deal with strong emotions, Francis says. So the district has been teaching young students how to identify when they’re becoming overwhelmed, name their feelings and use skills to calm themselves, such as breathing techniques, as well as letting them know whom they should contact within the school for additional help.

Self-regulation in a young student can mean the difference between moving on from a negative interaction with a peer on the playground or remaining upset the entire day, says Francis, an ACA member. Teaching young students these skills during elementary school may keep them from carrying over or forming difficult or unhealthy behaviors, such as skipping class, into middle or high school.

“The younger we can help kids know how to regulate their emotions and talk about their feelings, the better,” he stresses.

As manager of all the school counselors in the Minneapolis Public Schools, Francis often goes into classrooms to speak with students. During a recent session on “the power of words” with third, fourth and fifth graders, he sparked discussion by asking students for examples of incidents when they’d heard an “ouch” (hurtful) word and ways to respond when they are the recipient of or witness to an ouch word. The students had plenty of experiences with ouch words, including one kid who had been ridiculed for his lisp.

Francis then focused the conversation on social skills, empathy and ways to connect with people who come from different backgrounds. His overarching message to the students was that school should be an inclusive place, says Francis, a professional development specialist with Hatching Results, a company that provides training and continuing education for school counselors, administrators and school districts.

Francis says his district intentionally approaches hate and bias incidents in the same way they treat fire drills: It’s something for staff, students and parents to prepare for. That way, when something does happen, everyone knows how to talk about it, respond and connect with resources. 

The Minneapolis schools have also focused on the negative implications that social media use can have on student mental health. It’s become clear that students are saying hurtful things to each other online, not only on social media platforms such as TikTok and Snapchat but also via the chat feature on video games, group text messages and other avenues, Francis notes.

Adults don’t often realize how much of students’ lives are spent in the digital world, he says, and parents and students alike are not often aware of the connection between social media use and how a person feels about themselves. Many students do not have a parent or adult who monitors their dialogue on social media or helps them know when to log off or disregard negative comments, he adds.

“[Students’] brains are not developed yet to know how their words impact other people. It’s an area that needs a lot more development after the pandemic,” Francis continues. “The [effects of the] isolation of the pandemic, when paired with the negativity of social media, can really distract them from seeing positive things about themselves. We have to be mindful of the impact of screen time on students’ mental health. … It really impacts the school environment when it’s unaddressed.”

Forging connection

Holt and the other school counselors at her Atlanta-area middle school coordinate their schedules so they can visit and speak to the classrooms each fall. These visits serve as an opportunity to survey students on their mental health needs, and they also allow students to meet the counselors and learn more about the schools’ counseling programming.

The survey data they collect during these classroom visits informs the counselors’ focus for the year (e.g., the need for small groups to help students with anger, parental separation, grief or other issues) and also helps them identify and connect with individual students who are at risk, Holt explains.

Tracking student concerns and tailoring an appropriate counseling response are even more vital as mental health difficulties are on the rise.

Three students at Holt’s middle school have taken their own lives in the past five years. Part of the district’s response to the suicides, as well as to the overall increase of mental health needs, has been to establish a program that installs school-based therapists to provide long-term therapy for students. This year, Holt’s district has increased the number of school-based therapists to meet  the demand.

Holt’s school has also adopted several peer-based programs, including one that pairs established students with peers who are new to the district and another that trains students in suicide prevention and how to respond and connect a peer to appropriate help when they notice suicidal ideation (e.g., observing evidence of cutting in a peer as they change clothes for physical education classes).

The peer programming, counselor classroom visits and other recent initiatives are aimed at preventing students from falling through the cracks and help the counselors keep their finger on the pulse of the school, Holt explains. And it’s had a positive impact on school culture.

Like Holt, Henry feels that counseling staff need to be more visible and involved in their schools to respond to the recent rise in mental health needs. Now more than ever, school counselors need to get creative and set an example for other school staff by taking the first steps to forge connection with students, Henry says.

Long hours and heavy workloads leave teachers and counselors prone to burnout, but students also suffer when teachers and school staff focus on just getting through the school day and lose sight of the emotions and issues that students are dealing with beyond academics, stresses Henry, who is co-author of the 2019 book Mental Health in Our Schools: An Applied Collaborative Approach to Working With Students and Families. School staff who don’t take the time to connect with students, she says, risk not being able to recognize when a student is having an “off” day or exhibiting uncharacteristic behavior that indicates they need extra support.

School counselors can take steps to prevent this by encouraging teachers to spend time bonding with students at the start of the year, rather than diving into rigid topics such as classroom rules and expectations, Henry says. She notes that icebreaker activities, such playing bingo or prompting discussions about students’ favorite television shows or rides at a local amusement park, can make a big difference in fostering connection.

“And with that [activity] comes so much more dialogue,” she adds.

Henry also encourages counselors to be proactive and make their services known during team meetings and trainings among school staff. By emphasizing that their “door is always open” for collaboration when a student is struggling behaviorally or academically, counselors can help remind teachers that they are an important resource that can help address the underlying reasons for disruptive behavior or failing grades, such as anxiety, self-esteem issues or food insecurity at home. 

Henry says that improving student mental health and school culture is about school counselors “being present, being around [the] teachers and being around students as much as possible,” including in the hallways and at lunch. “And invite teachers to collaborate with you when a student seems ‘off,’” she adds. “When an adult reaches out, little things like that can change a kid’s life and make them feel like someone does care.”

Henry often offers to serve as a mediator between a teacher and a student when behavioral issues or conflict arises in the classroom. “I sometimes meet with a teacher behind the scenes to say, ‘Have you tried this?’ or ‘When I worked with this student, here’s what worked, here’s what he responded to,’” she explains. “It’s just like a [counseling] treatment plan; if something is not working, we move on and try something else.”

It’s easy for school staff to focus on what a student is doing wrong, she notes, but it’s more helpful to focus on what they’re doing right and emphasize their strengths. Offering students creative options beyond discipline and exploring the reasons why they’re struggling is key.

“We need to meet kids where they are,” says Henry, who counsels individual clients part-time at a private practice in addition to working as a school counselor. “Some of these kids just want to be heard. Just listening to what they have to say and not judging them makes a big difference. They need to feel like people [school staff] care.”

Barriers to behavioral health care 

School counselors are often the first mental health professional a student who is struggling with mental illness comes in contact with, notes Stephen Sharp, a school counselor at a middle school and coordinator for K-12 school counseling services in the Hempfield School District in the suburbs of Lancaster, Pennsylvania.

However, many students need long-term outpatient therapy that would not be appropriate or feasible for school counselors to offer. When students and families face barriers to access behavioral health care, it only adds to the increasing student mental health needs that schools are facing, notes Sharp, a member of the American School Counselor Association (ASCA) board of directors. 

The issue that Sharp says he finds most challenging is that for many of his students, all of their mental health support “begins and ends at the school walls.”

Sharp says he’s seen students go months without needed treatment because they were put on a waiting list for an appointment with a local mental health provider or they lack insurance or the ability to pay for treatment not covered by insurance. In some cases, undertreatment or lack of preventive treatment has led to student hospitalizations, he adds.

The biggest need for my students is access to ongoing behavioral health services,” he says. “The reality is that it [the gap in services] creates a disproportionate burden on the schools. Not just on school counselors but teaching staff as well.”

Sharp’s school district has a strong partnership with a local behavioral health provider who provides school-based services for students. However, he says that many students are not able to take advantage of the service. Both lack of insurance and limited coverage are barriers to treatment for students, he notes, but the latter is more pervasive. Students may have health insurance, but their plan may not cover certain services such as school-based therapy or virtual therapy, he explains.

There is also a shortage of behavioral health care providers just at a time when there is an increased demand for services. Sharp says that his school struggled this year to find a qualified school-based therapist to hire in addition to school counseling staff.

Sharp’s district is not alone in this phenomenon. Francis says that community mental health agencies in Minneapolis are also full and have waiting lists. In Texas, community resources that would otherwise provide support for families outside of schools, such as social service organizations, civic centers and nonprofit programs, are declining — and in some areas are nonexistent, Akins notes.

The pandemic revealed the cracks and flaws not only of our education system but also the health care and mental health care systems, Sharp notes.

“We are in a behavioral health care crisis, not just in the state of Pennsylvania but nationally as well, and it leads to a lack of access to care. Certain areas (e.g., rural) have always had a lack of care, but it’s gotten so much worse,” Sharp says. “All of this is really disheartening and challenging, but it’s also something that we absolutely as a profession and a society need to be talking about. What level of advocacy and coordination are we going to do to address these concerns?”

Sharp says the past year has been the hardest year yet for him professionally. But at the same time, he sees opportunity ahead.

One of the lessons gleaned from Hurricane Katrina, Sharp notes, is that a coordinated response works best in times of crisis, especially when there are financial strains and staffing limitations. There is an opportunity for national-level organizations such as ACA and ASCA to offer guidelines, training and other programming to address the rise inyouth mental health concerns, he says. And there is also opportunity for multidisciplinary collaboration. For example, the Pennsylvania School Counselors Association (PSCA) is working with the Pennsylvania chapter of the American Academy of Pediatrics to address the barriers to care in their state, he notes.

Support from professional organizations as well as collaboration among and across helping professionals at the local, state and national levels “makes things better but also makes us [individual counselors] feel like we’re not the only ones pushing against a brick wall,” says Sharp, a past president of PSCA. “The more innovative that we can get and share stories of success, those are the types of things that will lead to something better after this.”

All hands on deck

As a school counselor, Holt says that she sometimes thinks of her role as a “connector” between students and families and wraparound resources that can help meet their needs outside of school, including mental health services. However, she advises school counselors to only share resources that they are familiar with and have vetted to ensure that they offer quality services.

It’s helpful, Holt says, when a professional counselor contacts her school to let them know they offer group or individual services that are well-matched to their student population. She also recommends counselors have a list of local providers that they can offer to teachers and school staff who, like counselors, sometimes find themselves overwhelmed and in need professional support.

Holt encourages community counselors to connect with their local school counselors, and vice versa. “Having that connection from community mental health to the schools is very important,” Holt says. “The more resources that we [school counselors] know about, the more referrals we can do for our parents and students. If we don’t have connections in the community, it makes it harder. Being able to know that we have partners in the community and knowing what’s available is helpful.”

Akins agrees that partnerships between school and community resources will be key in addressing the recent increase in youth mental health needs. However, community counselors need to recognize that establishing helpful collaboration takes time and patience.

There are a lot of practical components that have to fall into place before a school can adopt a new program or resource, Akins notes. “Instructional minutes are very precious,” she says, so school officials cannot always justify using class time for mental health programming.

Akins suggests that community counselors get to know the unique needs of their local school district, as well as what has and hasn’t worked for other schools, before contacting their school to offer help.

In times of crisis, “sometimes people who are coming from the [nonschool] mental health community think ‘we don’t have time to waste.’ That’s true, but processes are in place for a reason (i.e., student safety),” Akins says. “Taking the time to really connect with your district and plan and develop a formal partnership will be a lot more successful than emailing a principal to ask, ‘Can I come in and do XYZ?’”

Sandi Logan-McKibben, a clinical assistant professor and school counseling program director at Sacred Heart University in Connecticut, asserts that counselors have an ethical responsibility to know what mental health and other wraparound resources are available in their area for clients and students.

She believes in this idea so strongly that she assigns her school counseling students a community mapping project each year. The students are charged with finding resources within the school district where they are working as a counseling intern and then overlaying those resources on a Google Maps image of the area. Students’ maps include not only mental health services but also after-school, tutoring and mentorship programs; organizations that help with food insecurity, homelessness or immigration services; nonprofit or faith-based organizations; and other institutions. 

This mapping project can be helpful for community and school-based counselors, whether they are students or not, adds Logan-McKibben, an ACA member.

She also recommends counselors find and help fill gaps in needed services. This can include anything from advocating for funding at a school board meeting or partnering with an existing nonprofit to expand services to contracting with a local university to offer pro bono counseling services for school students.

“It only takes one person to enact something and prompt change,” says Logan-McKibben, a former school counselor who lives in Florida and teaches virtually at Sacred Heart. “Find out what the actual needs of your community are. Don’t make assumptions. You don’t know unless you reach out.”

Counselors in all settings have a common skill — resourcefulness — and they need to draw on that skill to meet students’ needs in this time of crisis, Logan-McKibben says. This calls for counselors to work with a preventive, proactive and collaborative focus.

“The most important thing for all professional counselors to know is that we’re all in this together. Any kind of school crisis is really a community crisis,” she says.

Sharp agrees that counselors have a role to play in advocating for support for mental health care “both in and beyond the walls of the school.” This is a time to be concerned, he admits, but it’s also a time for meaningful work to be done.

“We also need to acknowledge the work that is being done and was done before [the situation became a crisis]. That work mattered before, and it matters now,” Sharp says. “Whether it’s school counseling or clinical counseling work we’re doing, it’s a sensitive time for the profession, … but [it’s] also a time to be mindful and reflective of victories and lessons learned. Also, [counselors should] take the time to celebrate. Celebrate the work our clients and students have done and use that to make the profession better.”


The influence of social and political issues on youth mental health 

Adults have been making a lot of decisions lately that not only create news headlines but also affect youth mental health, including a law aimed at making it easier for teachers to carry firearms in Ohio schools and the controversial Florida law — dubbed “Don’t Say Gay” by its opponents — that banned classroom instruction about sexual orientation or gender identity.

For school counselors, these issues are more than soundbites on news programs. They affect their students and families and add to the already complicated work school counselors are doing to combat a rise in suicidality and other mental health concerns in American youth.

Jessica Henry, a high school counselor in the Akron, Ohio, area, says she’s had coworkers who have refused to use a student’s preferred pronouns. “Not only is that unethical and has legal ramifications, it’s [also] very difficult to hear when a teacher says, ‘I’m not doing that,’” she says.

Henry, a licensed professional clinical counselor, feels that schools (and school counselors) should take a proactive role to address controversial issues rather than avoiding them. Students, parents and educators need to hear about topics such as racial injustice and LGBTQ+ inclusion, she says.

“We have to address the bigger picture of what is going on in our world. It’s about getting your administrators and superintendent to understand that inclusivity is vital — and in turn, will affect academics,” Henry explains. “It goes back to [asking], ‘Does every kid feel safe in their school?’ ‘Does every kid feel like themselves in their school?’ If even one student says ‘no,’ we’ve got work to do.”

Part of this work also involves the need for counselors to have the humility to recognize their biases, says Derek Francis, manager of counseling services for the Minneapolis Public Schools’ Department of College and Career Readiness. The majority of the counseling profession is white, yet the majority of many school populations are not, he notes.

“We need to be mindful of our biases. … It takes laying down your privilege and learning, open listening and connecting,” says Francis. “Ultimately, we’re trying to build trust when we’re doing counseling. We want all people to know that we have positive regard for them, and we need to come in [with] the right [unbiased] mindset to help the person in front of us.”

The growing polarization of political and social issues in America has also led to distrust of public institutions such as schools, says Jennifer Akins, a licensed professional counselor and president of the Texas School Counselor Association. She’s seen this mistrust spiral into parents equating terms such as “social-emotional learning” with critical race theory.

“We [school counselors] have been working on mental health issues and school safety for a long time, and many districts have integrated mental health and social-emotional learning [into the curriculum]. There is a segment of the public that has developed a mistrust even of those words, ‘social-emotional.’ They feel that things like mental health don’t really have a place in public education or are inappropriate. That stigma adds to some of the [mental health] needs we’re seeing in students. It’s disheartening,” says Akins, the senior director of guidance and counseling for the McKinney, Texas, public schools. “There’s very little disagreement that parents want to send their child somewhere where they’re cared about and where they’re safe. But the initiatives and programs that help enhance those things are the very things that they are scared into thinking are harmful and terrible.”

One way to reduce these patterns, Akins says, is for school counselors to make transparency and communication with parents about programming a priority, as well as involving parents in the creation of programs as much as possible.

She suggests that school counselors focus on messaging that emphasizes common ground: We all want children to feel connected, to belong and to feel safe, she notes, so open communication about what a school is doing for student mental health — and why you’re doing it — can be helpful. “It’s just a matter of peeling back some of the layers of misinformation,” Akins says.



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

Report: More than 1 in 5 children experience bullying

By Bethany Bray May 12, 2020

Bullying, a perennial issue for professional counselors who work with young clients both in and outside of school settings, remains prevalent among American youth. Researchers have found that more than one in five American youngsters experience bullying victimization from their peers – and prevalence is higher among children under age 12.

According to data from the National Survey of Children’s Health, parents of 22.4% of children ages 6 to 11 and 21% of adolescents ages 12 to 17 report their child “is being bullied, picked on, or excluded by other children.”

The data, compiled from the 2016-2017 National Survey, was published last month in the journal Public Health Reports by researchers from the U.S. Health Resources and Services Administration.

Researchers also parsed the data state-by-state in the journal article. The prevalence of bullying varied widely, from 16.5% of children in New York to 35.9% in Wyoming. Among adolescents, it ranged from 14.9% in Nevada to 31.6% in Montana.

Bullying among children or adolescents was greater than 30% in seven states: Arkansas, Kentucky, Maine, Montana, North Dakota, South Dakota and Wyoming.


Read the full report in Public Health Reports:  journals.sagepub.com/doi/10.1177/0033354920912713



Related reading, from Counseling Today:

Five social, emotional and mental health supports that teens need to succeed

Leading an anti-bullying intervention for students with disabilities

When bias turns into bullying

Bullying: How counselors can intervene



ACA resources:

 Journal of Counseling & Development articles:

ACA practice briefs

  • Youth Bullying Prevention
  • Bullying Intervention


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


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

The Counseling Connoisseur: How to talk to children about the coronavirus

By Cheryl Fisher March 17, 2020

The novel coronavirus, which causes the respiratory disease COVID-19, has made headlines for several weeks and has drastically impacted life as we know it. The outbreak, which the World Health Organization recently labeled a pandemic, has disrupted global commerce, shaken the United States stock market and led to travel restrictions and international border closures. Here in the United States, in an attempt to slow the coronavirus spread, major events have been canceled, educational systems are resorting to online forums, and organizations are recommending that employees telecommute. Medical providers are offering telehealth services, and places of worship are examining alternatives to in-person worship services. As of March 13, President Trump declared a national emergency, which may bring additional restrictions.

The coronavirus and children’s mental health

Global anxiety is high, and our clients are negatively impacted as they stockpile supplies and prepare for the unknown. Meanwhile, in the midst of the chaos, children struggle to make sense of all that they are seeing and hearing. Overwhelmed with information, children are responding in a variety of ways. Professionals who work with children report an increase in insomnia, rumination, intrusive thoughts, nightmares, and acting out behaviors.

“After twenty years of successful classroom management, I am finding it hard to command the attention of kids whose energy is so amped up,” says Steff Linden, an educator and children’s mindfulness yoga instructor in Annapolis, Maryland. “They are running around, tripping over themselves, and bumping into each other. These behaviors are examples of children who are overstimulated. They know something is going on, but they don’t know how to react, and they feel helpless and stuck.”

Children can’t escape the tension created by the viral crisis, so they begin creating an understanding which is often complicated by misinformation. “I had a kid poke his finger in my arm and yell, ‘You’ve got the coronavirus! I touched you!’” Linden reports.

Children are acting out their fears through behavior and play. Therefore, it is vital to address their concerns in a way that is reassuring and honest. Here are some tips for talking to children about the coronavirus: The acronym CAPES.

C: Create a calm setting. Children pick up on the emotions of the adults around them. Adults need to manage their anxiety before attempting to address the concerns of children. It is essential to provide a calm setting before talking with children about COVID-19.

A: Ask what they already know. Children are already talking about the virus. They may have misinformation that needs to be corrected. Ask children what they have heard about the virus? Ask them about their concerns and fears. Children tend to worry about their own safety and those in their immediate world such as friends, family members, and even pets.

P: Provide age-appropriate answers. Answer children’s questions with honest, factual and age appropriate answers. Provide answers that are bias-free. Explain that COVID-19 is caused by a new virus and makes people feel sick with a cough and fever. Help battle stigmatizing any particular population by emphasizing that the coronavirus is no one person or country’s fault.

E: Empower them with tools. Children feel powerless over this big virus that has people buying out toilet paper and Clorox wipes. Provide them with actual tools to use that will be empowering by teaching them to wash their hands using soap and water while singing a happy tune for twenty seconds, cough or sneeze into their elbows—not their hands—or a tissue that they immediately toss in the trash and use no contact greetings such as jazz hands or Namaste.

S: Safety. Children turn to adults for a sense of safety and well-being. Assure children that it is not their job to worry about the virus and that you have a plan in place to care for them. Explain ways that you are keeping them safe by making sure they get enough sleep and providing them with nutritious meals. Tell them that their regular visits to the pediatrician and daily vitamin (if they take one) help keep them healthy. Even with school closings, provide daily structure that includes time for non-directed play to help children act out and process feelings. Help them make a list of ways they are healthy and safe. There are a lot of unknowns with COVID 19, so focus your conversation on what is known.


As counselors, we can help parents and our child clients better manage the plethora of information that is available. We can assure children that the adults in their lives are up for the task of taking care of them. The acronym CAPES can remind us how to be superheroes in an effective way to the young members of society who are powerless.

And, as always, we must remember our own self-care during this challenging time. Take a peek at my thoughts around a counselor’s guide to surviving flu season my column from February 2018, “The Counseling Connoisseur: Compassion and self-care during flu season.”



Important links:

COVID-19 update and resources from Counseling Today

COVID-19 related resources from the American Counseling Association



Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online MA in Clinical Counseling.  Her research interests include examining sexuality and spirituality in young women with advanced breast cancer; nature-informed therapy; and geek therapy. She may be contacted at cyfisherphd@gmail.com.



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.