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Jessica Paris

Mental Health and Wellness Counseling M.A.

One personal goal is for me to become more self aware of my own biases, values, and emotions. Recognizing personal limitations, staying mindful of cultural differences, and continuously reflecting on your own reactions.

My professional goal I want to continue to have ongoing professional development and staying updated on the latest therapeutic techniques and research.

What I hope to gain from this course is to better understand the psychological impact of trauma, crisis intervention techniques, and skills for providing support to individuals experiencing trauma.

With a foundation in Multicultural Women and Gender Studies, my objective is to acquire insights that will elevate my cultural competency proficiency.

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In exploring mental health concerns, I gained insights into depression, anxiety, substance use, and eating disorders. The unit explored into the details of each issue, discussing their causes, and stressing the significance of early intervention. Recognizing the crucial role of early intervention in preventing the worsening of anxiety symptoms, I developed a deep understanding of its importance.

While I had not researched panic disorder extensively, I acknowledge the need to enhance my knowledge as a future therapist. Additionally, understanding phobias is essential, as some individuals may have irrational fears. The unit highlighted the impact of alcohol, emphasizing how alcoholism can lead to dependence, creating a strong urge for alcohol and causing difficulties in daily functioning without it. I've gathered information on various disorders like Schizophrenia, Bipolar Disorder, and Psychotic Depression, which I believe will be valuable in my future career as a counselor.

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Depression is an

illness that affects the way you feel about yourself,

other people, and things in life, day after day.

Anxiety is a feeling marked by tension, worried thoughts, and physical changes such as increased blood pressure. People with anxiety disorders often experience repeated intrusive thoughts or concerns and might avoid certain situations due to worry. Physical symptoms like sweating, trembling, dizziness, or a fast heartbeat can also accompany anxiety.

Psychosis is the term for a collection of symptoms that happen when a person has trouble telling the difference between what’s real and what’s not. This disconnection from reality can happen for several reasons, including many different mental and physical conditions. It’s usually treatable with medication and other techniques.

Substance use disorder (SUD) is a complex condition that involves a problematic pattern of substance use. It can range from mild to severe (addiction). SUD is treatable. It’s important to seek help as soon as possible if you think you or your child is developing SUD.

Eating disorders are serious health issues that impact both your body and mind. They involve difficulties in how you think about food, eating, and your body, as well as how you behave when it comes to eating. These problems can affect your overall health, emotions, and your ability to manage important aspects of life.

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The Mental Healthcare Act 2017 (MHCA 2017),[ 1] explicitly talks about the rights of patients with mental illness (PWMI) and lays down the ethical and legal responsibilities of mental health professionals and the government. The rights of PWMI are at par with the fundamental rights of human beings and need to be clearly talked about as they belong to a vulnerable group from evaluation, treatment, and research perspectives. Such rights translate into the ethics of psychiatric care that relate to respect for autonomy; the principle of non-maleficence, beneficence, and justice; confidentiality (and disclosure); boundary violations; informed consent (and involuntary treatment); etc.[ 2, 3] I will discuss the ethical, legal, and related issues pertaining to the manuscripts published in this issue of the journal.

THE MENTAL HEALTHCARE ACT 2017

In their article pertaining to MHCA 2017, the authors,[ 4] critically evaluate the pros and cons of the new ACT. They commend the act for endorsing the rights (especially insurance) of PWMI and recommending decriminalization of suicide and the lesbian, gay, bi-sexual, transgender, questioning/queer (LGBTQ) community. They also mention the non-representation of the Indian Psychiatric Society and inadequate address of the burden of care experienced by the caregivers. The caregivers of PWMI are the real ambassadors of mental health; they sincerely understand the genuine service that psychiatrists have provided in this country over many decades. No doubt, human rights of PWMI have to be protected at all times; however, it cannot be one-sided. There is an equal and strong need to involve the caregivers in framing mental health policies that are ethically and legally sound and at the same time tailoring to their needs and the ground realities of this developing country, such as poverty, illiteracy, unawareness regarding mental illness, stigma, discrimination, etc. In view of the new challenges thrown by MHCA 2017, such as mental health capacity assessment, advance directive, nominated representative, etc., the authors stress regarding the need to actively collaborate with "the media, police, NGOs, human rights activists ... and police."[ 4]

ETHICAL ISSUES

Ethic is defined as "a set of moral principles, especially ones relating to or affirming a specified group, field, or form of conduct."[ 5] Technically, ethics talk about morality and desirable way of behaving but may not be binding on an individual. However, when it comes to medical ethics, these are essential (not desirable) requirements based on which a physician is mandated to act. The legal aspects of patient care are determined by country-specific regulations, which in turn are governed by medical ethics. For instance, when an Indian psychiatrist is alleged of "wrongdoing," it is determined whether he acted contrary to "medical ethics,"[ 6] or to the pertaining laws in the country.[ 1] Thus, the ethical and legal responsibilities of a psychiatrist are intertwined.

Confidentiality and disclosure

The patient-physician relationship is bound by the moral and ethical sanctity of confidentiality, more so in mental health. This is one of the fundamental responsibilities of the psychiatrist.[ 1, 6] In clinical practice, however in certain situations, the PWMI themselves waive-off this confidentiality clause. In India, PWMI are mostly accompanied by caregivers. Few PWMI wants their information and diagnosis to be disclosed to such caregivers. Considering this as implied consent, till some time back, such disclosure was done in the absence of an explicit written informed consent. A typical scenario would be a lady under treatment for psychiatric illness for the previous 10 years suddenly turns up to the treating psychiatrist and discloses that she got married around a month back and now plans to conceive. Her spouse also wants to discuss regarding the diagnosis, treatment, and the need for and the safety of psychotropics in pregnancy. The spouse may, unfortunately, use the disclosed information for any purpose (including divorce) and the lady may sue the treating doctor for breaching the confidentiality. Hence, as the lady herself wants her information to be shared with her spouse and the confidentiality clause is going to being breached, written informed consent should mandatorily be obtained from her, including permission as to how much can be disclosed and this should be documented in the patient's notes. Such written authorization from the patient may protect the psychiatrist in the Court of Law.

It is interesting to know the sociodemographic variables that determine such disclosure. Gupta et al.[ 7] conducted a study on remitted psychiatric patients. Younger age, female gender, and higher educational status were more significantly associated with the patients' unwillingness to disclose their concerns with others. The authors recommend that these factors may be considered when making ethical decisions.

Lack of adequate information regarding forensic patients with mental illness

Diagnosis is of paramount importance to manage psychiatric patients effectively which rests on adequate history from significant others, as psychiatrists cannot rely solely on mental status examination. When individuals are admitted involuntarily through Honorable courts and prisons into tertiary level public hospitals, there is a lack of adequate history. This is more common with those referred from prisons. Attempts are made to discuss with the prison medical officer and caregivers. The caregivers are either untraceable or unwilling to discuss. Also, because of unawareness regarding mental disorders, the only history obtained from the medical officer is of the patient being irritable or displaying suicidal threats. This is not enough to arrive at a diagnosis. Thus, the lack of adequate history is a major problem in a forensic psychiatric setting. The management of such patients, thus, is mostly based on inpatient observation. In recent times, in India, there is an increased focus on training of judiciary and prison medical officers which is a welcome step. There is also a dire need to have a judicial policy that mandates caregiver's and/or family member's presence while referring such individuals to psychiatry hospitals.

With this background, a retrospective chart review was conducted on female forensic inpatients.[ 8] About 73.9% of the sample was referred from prisons and 26.1% from the Honorable courts. In view of the alleged crime, 21.7% of subjects were referred for assessment of fitness to stand trial. Majority of them (30.43%) were charged with the killing of close family members, such as husband or child. On retrospective evaluation, approximately half of the study sample had an illness at the time of occurrence of the crime. About 30.4% of the individuals were diagnosed as having psychotic disorders, and 47.8% had a mood disorder. A significant clinical improvement was reported in 87% of patients which is encouraging. It remains to be seen whether the improvement gained persist in the long term, especially those referred from prisons. Also, how such patients fare after discharge from the psychiatry hospital and after release from prisons, because of treatment nonadherence and other prognostic factors? This study focused only on female gender; do male forensic patients fare differently?

LEGAL ISSUES IN PSYCHIATRIC CARE

Psychiatrist appearing in the Court

In their article, "Psychiatrist in Court: Indian scenario,"[ 9] the authors discuss the legal aspects of psychiatric care when psychiatrists are summoned as an expert witness. They opine that the "psychiatry residents often do not get first-hand exposure to the Court proceedings." The reason for this may be threefold. First, many residents get trained in General Hospital Psychiatry Units (especially, private colleges) that are not directly attached to forensic psychiatry units. They have a peripheral posting of just around 2-4 weeks to such centers. Second, the residents, being doctors-in-training, work under the supervision of faculty; hence, the Honorable courts do not consider them competent to give evidence. Third, the faculty members may not involve them in legal aspects of patient care, believing it is not their responsibility. In my place of work, which is a tertiary level teaching public hospital, the psychiatry residents are routinely involved in legal aspects of patient care. The faculty should make sure that the residents are actively involved in the legal aspect of patient care, such as medical boards, discharge committee meetings, certification, etc. Only when they are exposed at this stage of their career, once out of residency, they would be in a position to manage such issues independently.

Outcome of insanity pleas

The psychiatrists appear in Honorable courts as an expert witness and give evidence but are unaware as to what happens later. I commend the investigators for researching a hitherto underresearched topic in Indian scenario,[ 10] relating to insanity pleas.[ 11] If an accused has a proof that he was under treatment prior to the crime, the treating psychiatrist is likely to be summoned; in 32 out of 67 cases (47.76%), the treating psychiatrist was asked to appear. The time interval between the "visit to a psychiatrist" and the subsequent "date of crime" ranged from 1 to 1800 days, which is alarming in the sense that a PWMI may commit crime immediately following the consultation. More so, if there is a documentary evidence of mental illness, there is a higher chance ( P < 0.012) of acquittal on the grounds of mental illness. Both in those cases where the Honorable Court did not feel the need for psychiatrist's evidence (24 cases) or in those six cases where the psychiatrist opined that there was no mental illness, the accused was not acquitted on the grounds of mental illness. Also, the 16 out of 56 accused (28.57%), who had mental illness as per psychiatrists' opinion, were acquitted on the grounds of mental illness ( P = 0.002). The 18 (17.65%) cases out of a total of 102 cases were acquitted on the grounds of mental illness. The Honorable High Courts' judgment was mostly in line with the judgment of the lower Court and heavily relied on the documentary evidence of mental illness. The psychiatrists' opinion was an important parameter, which is quite encouraging. The results strongly point toward the need for proper documentation.

Absconding behavior in patients with mental illness

When PWMI abscond from psychiatric hospitals, especially closed wards, it places an enormous burden on the hospital staff in terms of the legal implications. The absconders may not take care of self and may be at risk of harm to self, others, and property. Though absconding from psychiatric hospitals or nursing homes is quite common, no Indian data are available in the published literature, probably because of the concern that it may reflect negatively onto the staff and hospital administrators. Though this is an unfortunate event, we need not feel inhibited researching this as absconding is common in any closed setting including high secure prisons[ 12] and general hospitals,[ 13] and psychiatric hospitals worldwide,[ 14, 15, 16] and in India,[ 17] are no exception.

It is heartening to note that an article dealing with this important, albeit unaddressed issue is published.[ 18] Among the in-patients, the absconding behavior was found in 4.5% of the individuals. They were mostly males, with a diagnosis of schizophrenia or mood disorder with comorbid substance-use disorder, with impaired insight and high perceived coercion being the predictors of absconding behavior. About 22.2% of the nine absconders committed suicide. A previous history of self-harm and wandering away from home in those absconded points toward the need to inquire regarding this as part of history taking. This study focused on open wards where PWMI consent for admission and the caregivers who stay are responsible for patient care. It is pertinent to study absconding behavior in the closed ward setting where PWMI are admitted involuntarily (through courts and prisons) without caregivers, thus placing more "responsibility" on the hospital authorities. There is a dire need to employ polices to prevent such incidents by rationalizing pharmacotherapy; adequate use of restraints and seclusions as per guidelines;[ 1] electroconvulsive therapy for agitated patients; strengthening the hospital security by constructing stronger wards with tall walls and fencing, adequate personnel, sophisticated gadgets, and alarms; timely discharge from the hospital; etc. It also points to the need for prison mental health services where forensic patients can be managed securely in the prison itself.[ 19]

For patients with severe mental retardation, dementia, and severe and enduring obvious mental illnesses, such as severe psychosis, who are at risk of absconding behavior, few of my psychiatry colleagues as part of informal discussion suggested use of metal bracelets (kadas that are religiously acceptable) with details engraved (names, phone numbers, and address of patient and caregiver); bands; and implants, gadgets, watches, and chips with GPS location device and trackers. However, these need to be used after obtaining written informed consent, but the concerns expressed are cost, need for battery charging, can be thrown away, technology not so advanced for universal application, etc. Other concerns expressed were ethical and legal issues, stigma, restriction of civil liberties, violation of privacy, infringement to capacity, practicality, etc. The tattoos with name, phone, and address of the caregiver seem to be a reasonable option, as these cannot be discarded and may have a fashion statement, the future suggestion being tattoos with radioactive (but safe) traceable ink material that can be tracked ( in a conversation with Live CME Psychiatry WhatsApp group members: 2019 Feb., 06). However; based on ethical and legal guidelines, these need further discussion before implementation.

DISABILITY BENEFIT OF PERSONS WITH MENTAL ILLNESS

Disability in mental illness is a state where the patient has shown symptomatic recovery with the available treatment modalities, however, has deficits that lead to significant problems with self-care, interpersonal, social, and occupational functioning, and impaired quality of life that may need aggressive rehabilitation.[ 20, 21] Balakrishnan et al.[ 22] scholarly reviewed various aspects of the Rights of Persons with Disabilities Act, 2016,[ 23] especially regarding the certification guidelines. They point toward the ambiguity related to screening instruments, resource allocation, and the need for inclusive education. They recommend increased focus and reservation for patients who have a disability due to mental illnesses and specific learning disorders; and decentralization of the disability certification, for example, certification of severe or profound intellectual disability at the primary health center (PHC) itself. This would prevent inconvenience to end users, reduce workload at tertiary level psychiatric centers, would be cost-effective and less time consuming, and would lead to higher recruitment of mental health professionals, especially qualified psychiatrists and clinical psychologists at PHC itself. However, such certification should be done by a medical board mandatorily comprising a qualified psychiatrist and clinical psychologist and not by other professionals such as pediatricians.

"With rights, come responsibilities!" "An individual has a mental illness, is aware of it, exercises his right to not take treatment, commits a crime, attributes the crime to mental illness, and claims no responsibility for the crime as it was due to the mental illness." An example in the context of disability would be that few patients have insight into their mental illness with intact mental capacity but exercise their "right to refuse treatment." Thus, they do not want to take responsibility for getting treated. However, to avail benefits, they "claim disability" on the grounds of mental illness. How can such an individual exercise his right to refuse treatment; but at the same time claim "benefits" related to his mental illness?

The poverty of our patients may sometimes override our clinical assessment; however, it is the State's responsibility to take care of the financial status of its citizens. Psychiatrists should only be concerned about mental illness and the resulting disability. Thus, even a rich person who has a disability due to mental illness should get disability benefits. The disability benefits must be independent of the financial status of PWMI. A limited budget is allocated for disability benefits, and improper certification may prevent benefits to really deserving PWMI; such individuals should be carefully evaluated. This is of paramount importance in general hospital psychiatry units where the nonpsychiatric medical professionals may not be aware of the real concept of disability due to mental illness, hence may fail to understand as to why a particular procedure is being followed by the psychiatrists. We need to educate them regarding the legal intricacies of dealing with PWMI.

CONCLUSION

Every PWMI is a potentially medicolegal case unless proved otherwise. However, we need not be fearful but cautious while evaluating and treating them and be aware of the legal angle which ultimately boils down to the ethical aspects. It is paramount that the fear of being accused of "violation of rights" should not prevent us from providing legally sound ethical psychiatric care in the "best interest" of the PWMI, vis-à-vis responding to the genuine concerns of caregivers, especially parents who bear the brunt of patients' illness.

"All approaches to medical ethics, be they empirical, legal, sociological, theological or philosophical should aim at being practically useful ... good medical ethics must help inform and guide those who are directly involved in moral issues in medicine and healthcare. This means that above all, good medical ethics is clinically relevant."[ 24]"The need is for balancing idealism with pragmatism of how much is feasible and how much should be attempted."[ 25] It is important that the medical ethics should not become archaic impractical laws; but scientifically sound, implementable guidelines taking into consideration the ethos, and these should be periodically updated.

Acknowledgment

I thank the Live CME Psychiatry WhatsApp group admin Dr. M. Aleem Siddiqui, MD, DPM for permitting me to cite the conversation relating to absconding behavior in PWMI.

REFERENCES

2. Agarwal AK, Gupta SC. Ethics in psychiatry. In: Vyas JN, Ahuja N, editors. Textbook of Postgraduate Psychiatry. JPB Publishers; 2003. [ Google Scholar]

13. Khammarnia M, Kassani A, Amiresmaili M, Sadeghi A, Karimi Jaberi Z, Kavosi Z. Study of patients absconding behavior in a general hospital at southern region of Iran. Int J Health Policy Manag. 2015;4:137-41. [[ PMC free article] [ PubMed] Google Scholar]

Articles from Indian Journal of Psychological Medicine are provided here courtesy of Indian Psychiatric Society South Zonal Branch

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Legal and Ethical Aspects of Mental Health Care

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The Mental Healthcare Act 2017 (MHCA 2017),[ 1] explicitly talks about the rights of patients with mental illness (PWMI) and lays down the ethical and legal responsibilities of mental health professionals and the government.

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Substance Abuse and Mental Health Services Administration

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Frequently Asked Questions - What is SAMHSA’s National Helpline?

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NAMI, the National Alliance on Mental Illness, is the nation's largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness.

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Home | NAMI: National Alliance on Mental Illness

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NAMI, the National Alliance on Mental Illness, is the nation's largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness.

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Reflection: Introductions and Assessing Prior Knowledge

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Reflection: Introductions and Assessing Prior Knowledge

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In reflecting on this assignment, I find a profound sense of connection with my classmates, especially Wendy. Exploring her journey from a middle school Special Education teacher to a high school counselor in the DFW area highlighted the transformative power of educational experiences. Witnessing her dedication to the LPC Bridge program and her aspirations to become a therapist in the school district's counseling clinic resonated deeply with my own commitment to cultural competence in counseling.

Furthermore, the exchange with Wendy and her experiences reinforced the importance of crisis intervention and trauma response in our field. Learning from her proactive approach and the steps she takes to support students facing mental health challenges has broadened my understanding. This assignment has served as a catalyst for appreciating the real-world applications of our coursework, fueling my motivation to further explore and integrate these insights into my role as a cultural competence counselor. Overall, it has been a valuable exercise in fostering connections, gaining practical perspectives, and solidifying my dedication to making a positive impact in the mental health field.

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Non‑suicidal Self‑injurious Thoughts and Behaviors Among

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Non‑suicidal Self‑injurious Thoughts and Behaviors Among

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Adolescent Inpatients

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Non‑suicidal Self‑injurious Thoughts and Behaviors Among

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Mood Disorder Severity and Subtype Classification Using

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Mood Disorder Severity and Subtype Classification Using

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Multimodal Deep Neural Network Models

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for residential substance use disorder

treatment facilities: former clients’

perspectives

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Ethical Dilemmas Facing Substance Use Counselors

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Ethical Dilemmas Facing Substance Use Counselors

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During the COVID-19 Pandemic

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Ethical Dilemmas Facing Substance Use Counselors

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This week's lesson provided valuable insights into various aspects of trauma, including primary trauma, secondary trauma, acute trauma, chronic trauma, and the effects of burnout. As a counselor, understanding these different forms of trauma is essential for effective assistance.

One of the most impactful ways a counselor can contribute to trauma management is through early prevention, achieved through thorough assessments and carefully crafted treatment plans. By paying close attention to signs and symptoms, counselors can identify and address experiences of trauma, not only in adulthood but also during the crucial developmental stages of early childhood.

The lesson highlighted the enduring impact of trauma on adults, revealing how it can have long-lasting or even permanent effects on the way individuals experience life and make decisions. Furthermore, it shed light on the potential mental health implications for both the individual and their relationships with family and friends.

In summary, the lesson emphasized the importance of counselors being proactive in trauma prevention, recognizing the signs across various life stages, and understanding the profound and lasting effects that trauma can have on individuals and their social connections.

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American Counseling Association Knowledge Center

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American Counseling Association Knowledge Center

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The American Counseling Association Center for Practice, Policy, and Research is responsible for providing access to, and interpretation of, the American Counseling Association Code of Ethics. This web page provides ACA members and members of the public with the necessary tools to ensure compliance with the ethical standards of the counseling profession.

Although ethics and risk management are related, ACA does not offer risk management services such as advice to minimize risk in the event of lawsuits and/or criminal charges. ACA believes that whenever questions arise, counselors should consult with a lawyer licensed in the jurisdiction in which they practice. More information is offered in the Risk Management section below.

The 2014 update to the ACA Code of Ethics is the first edition that covers the ethics of using social media with clients. This edition also presents new or expanded guidelines on distance counseling, confidentiality, extending boundaries, multiculturalism and diversity, the use of technology, record keeping, diagnosis, end-of life care, the selection of interventions, and preventing the imposition of counselor personal values,

View the 2014 ACA Code of Ethics (PDF)

The 2014 ACA Code of Ethics is also available:

To cite the ACA Code of Ethics as a resource for an academic work, use the following:

American Counseling Association. (2014). ACA code of ethics. https://www.counseling.org/resources/aca-code-of-ethics.pdf

To view previous editions of the Codes of Ethics, visit our Ethics Archive.

The American Counseling Association is pleased to help members with inquiries on ethical practice, career counseling and advice regarding the profession.

Please kindly note that this service is not designed to function as a real time hotline. Inquiries are prioritized, and the ACA standard practice is to respond within three business days of receipt.

Please send an email request to consult@counseling.org to schedule a consultation.

Thank you in advance for your patience.

The ACA Ethics Committee is responsible for processing complaints of alleged violations of the ACA Code of Ethics. To file a complaint against a counselor who is an active ACA member, please review the Policies and Procedures for Processing Complaints of Ethical Violations. After reviewing the Policies and Procedures for Processing Complaints of Ethical Violations, begin the complaint process by sending an email to ethics@counseling.org

Although ethics and risk management are related, the American Counseling Association no longer offers risk management services such as advice to minimize risk in the event of lawsuits and/or criminal charges.

Risk management is a very complex area. ACA believes that, whenever questions arise, counselors should consult with a lawyer licensed in the jurisdiction in which they practice.

One resource, recommended by Anne Marie "Nancy" Wheeler, former ACA Risk Management Consultant, is Martindale.com, an online legal portal that can be used to search for attorneys. ACA has no affiliation with Martindale and does not endorse the attorneys listed on the company's website. Be certain to verify the credentials and past work of all prospective legal advisers.

In addition, professional counselors should use all of the services available to them through their liability insurance provider. In the event of a licensure complaint or professional liability incident or notice of complaint, ACA members insured through HPSO should call 800-982-9491, or go to hpso.com for more information.

To view previous risk management columns by Anne Marie "Nancy" Wheeler, J.D., as well as other resources, visit the ACA Risk Management page.

Each month, experts in ethics explore real-world issues in Counseling Today through the lens of the 2014 ACA Code of Ethics. Visit our Ethics Update page to access past columns.

Difficult situations can arise in any counseling setting, and when they do, counselors "are expected to engage in a carefully considered ethical decision-making process," as recommended by the 2014 ACA Code of Ethics.

Holly Forester-Miller, PhD, and Thomas E. Davis, PhD, collaborated with the American Counseling Association to publish a white paper titled "Practitioner's Guide to Ethical Decision Making" (2016). For more information and to read the white paper, visit the ACA Ethical Decision-Making page.

There are many ways to engage with and/or learn about the 2014 ACA Code of Ethics. Visit the Code of Ethics Resources page to find out more.

If you are looking for resources related to previous editions of the Codes of Ethics visit our Ethics Archive.

ACA offers a number of resources, including consultation, regarding licensure. Visit the ACA Licensure Requirements page for more information. To request a consultation about licensure, email acacareers@counseling.org.

The Graduate Student Ethics Awards, with separate categories for master's degree and doctoral degree students, reward the exceptional and demonstrable understanding of the ACA Code of Ethics.

To read the statement, click here.

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The American Counseling Association Center for Practice, Policy, and Research is responsible for providing access to, and interpretation of, the American Counseling Association Code of Ethics . This web page provides ACA members and members of the public with the necessary tools to ensure compliance with the ethical standards of the counseling profession.

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The Trevor Project | For Young LGBTQ Lives

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The Trevor Project provides 24/7 crisis support services to LGBTQ young people. Text, chat, or call anytime to reach a trained counselor. Free and confidential.

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Artifact Introductions and Assessing Prior Knowledge
 

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Artifact Introductions and Assessing Prior Knowledge
 

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Legal Action Center | Breaking Barriers. Defending Dignity.

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LAC uses legal & policy strategies to fight discrimination, build health equity & restore opportunity for people with criminal records, addiction, or HIV.

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We're so glad you found us! PFLAG is the nation's largest organization dedicated to supporting, educating, and advocating for LGBTQ+ people and those who love them.

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People without health insurance often find themselves with limited options for affordable healthcare and free dental care, and their lives and health often depend on access to free medical clinics. Free Clinic Directory is the premier online destination for uninsured people to connect with affordable and free health clinics in their area. By clicking on a state, a person can find free and affordable clinic listings by county.

Each clinic listing comes with a wealth of information, including reviews, services provided and contact information. Clinic administrators can easily add listings to FreeClinicDirectory.org, and people who have used any of the listed clinic services can easily post reviews. Full clinic information is available to people who register for a free account.

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Free Clinics and Community Health Centers | Low Cost Dental Care

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Free Clinic Directory offers listing of thousands of free and affordable clinics throughout the United States.

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Eating disorder hotlines are dedicated helplines offering assistance, information, and support for individuals dealing with eating disorders. Staffed by trained professionals, they provide a safe space to discuss struggles, seek guidance, and receive referrals for treatment options and emotional support.

Eating Disorder Helplines

The Alliance for Eating Disorders Awareness Helpline

The Alliance for Eating Disorders Awareness Helpline offers support and resources for individuals dealing with eating disorders. Whether someone is struggling with anorexia, bulimia, binge eating disorder, or body image issues, the helpline is there to provide compassionate assistance on the journey towards recovery and healing.

Mental Health Hotlines

Mental health hotlines aim to ensure that individuals in need have a safe space to talk about their feelings, receive guidance, and access appropriate help and resources for their mental well-being.

Crisis Text Line

Crisis Text Line is a confidential support service that provides help and resources to individuals in crisis. Through text messaging, trained crisis counselors offer a listening ear, emotional support, and information on available resources.

Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline

SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities. They work to promote behavioral health, provide access to treatment and recovery services, and support prevention and early intervention efforts.

National Alliance on Mental Illness (NAMI) Helpline

The NAMI helpline offers information, resources, and compassionate assistance for individuals seeking help for mental health concerns. Staffed by trained volunteers and professionals, the NAMI Helpline provides a safe space to discuss mental health challenges, access resources, and receive referrals to local support services.

National Domestic Violence Hotline

The National Domestic Violence Hotline is dedicated to empowering survivors of domestic violence and raising awareness about the issue to promote safety, healing, and prevention.

LGBTQ+ National Hotline

The LGBTQ+ National Hotline addresses a wide range of concerns, including coming out, relationships, mental health, and more. It aims to provide an affirming and inclusive space for individuals to share their stories and find understanding and assistance on their journeys.

Veterans Crisis Line

The Veterans Crisis Line is a confidential support service provided by the U.S. Department of Veterans Affairs (VA) for veterans, service members, and their families. The goal of the Veterans Crisis Line is to ensure that veterans and their loved ones receive the help and support they need during difficult times, fostering a safe and supportive space for those who have served our country.

Academy of Nutrition and Dietetics' Food and Nutrition Hotline

Whether someone has questions about meal planning, special dietary needs, weight management, or general nutrition, the Food and Nutrition Hotline serves as a trusted resource to promote informed and healthy food choices for individuals and families.

Association for Size Diversity and Health (ASDAH)

ASDAH is a non-profit organization dedicated to promoting size-inclusive healthcare, body respect, and ending weight stigma. They advocate for the Health at Every Size (HAES) approach, emphasizing the importance of holistic health and well-being independent of body size. Their website offers resources, webinars, and information on body positivity and HAES principles.

National Eating Disorders Association (NEDA)

NEDA is a non-profit organization dedicated to supporting individuals affected by eating disorders. While not solely focused on body positivity, they promote body acceptance and work towards eliminating body image issues. They offer helplines, resources, and educational materials on eating disorders and body image concerns.

The Body Positive

The Body Positive is a non-profit organization that empowers individuals to cultivate self-love and a positive body image. They offer workshops, educational programs, and online resources to promote body acceptance and resilience. Their approach emphasizes self-care, self-compassion, and body neutrality.

Be Nourished

Be Nourished is a body trust organization that offers workshops, trainings, and resources centered around body acceptance and healing from disordered eating. They emphasize the importance of body autonomy, intuitive eating, and challenging diet culture.

The Center for Mindful Eating

The Center for Mindful Eating is a non-profit organization that promotes mindful eating practices to support a healthy relationship with food and body. They offer resources, webinars, and professional training to promote a compassionate and non-judgmental approach to eating.

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Eating Disorder Hotlines for 24/7 Crisis Help

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NEDA no longer maintains an eating disorder hotline - Get help now - Eating Disorder Hope provides several helplines and online resources

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What are eating disorders?

Eating disorders are serious mental health disorders. They involve severe problems with your thoughts about food and your eating behaviors. You may eat much less or much more than you need.

Eating disorders are medical conditions; they are not a lifestyle choice. They affect your body's ability to get proper nutrition. This can lead to health issues, such as heart and kidney problems, or sometimes even death. But there are treatments that can help.

What are the types of eating disorders?

Common types of eating disorders include:

Binge-eating, which is out-of-control eating. People with binge-eating disorder keep eating even after they are full. They often eat until they feel very uncomfortable. Afterward, they usually have feelings of guilt, shame, and distress. Eating too much too often can lead to weight gain and obesity. Binge-eating disorder is the most common eating disorder in the U.S.

Bulimia nervosa. People with bulimia nervosa also have periods of binge-eating. But afterwards, they purge, by making themselves throw up or using laxatives. They may also over-exercise or fast. People with bulimia nervosa may be slightly underweight, normal weight, or overweight.

Anorexia nervosa. People with anorexia nervosa avoid food, severely restrict food, or eat very small quantities of only certain foods. They may see themselves as overweight, even when they are dangerously underweight. Anorexia nervosa is the least common of the three eating disorders, but it is often the most serious. It has the highest death rate of any mental disorder.

What causes eating disorders?

The exact cause of eating disorders is unknown. Researchers believe that eating disorders are caused by a complex interaction of factors. These include genetic, biological, behavioral, psychological, and social factors.

Who is at risk for eating disorders?

Anyone can develop an eating disorder, but they are more common in women. Eating disorders frequently appear during the teen years or young adulthood. But people can also develop them during childhood or later in life.

What are the symptoms of eating disorders?

The symptoms of eating disorders vary, depending on the disorder:

The symptoms of binge-eating include:

Eating unusually large amounts of food in a specific amount of time, such as a 2-hour period

Eating even when you're full or not hungry

Eating fast during binge episodes

Eating until you're uncomfortably full

Eating alone or in secret to avoid embarrassment

Feeling distressed, ashamed, or guilty about your eating

Frequently dieting, possibly without weight loss

The symptoms of bulimia nervosa include the same symptoms as binge-eating, plus trying to get rid of the food or weight after binging by:

Purging, making yourself throw up or using laxatives or enemas to speed up the movement of food through your body

Doing intensive and excessive exercise

Fasting

Over time, bulimia nervosa can cause health problems such as:

Chronically inflamed and sore throat

Swollen salivary glands in the neck and jaw area

Worn tooth enamel and increasingly sensitive and decaying teeth. This is caused by the exposure to stomach acid every time you throw up.

GERD (acid reflux) and other gastrointestinal problems

Severe dehydration from purging

Electrolyte imbalance, which could be too low or too high levels of sodium, calcium, potassium and other minerals. This can lead to a stroke or heart attack.

The symptoms of anorexia nervosa include:

Eating very little, to the point of starving yourself

Intensive and excessive exercise

Extreme thinness

Intense fear of gaining weight

Distorted body image - seeing yourself as overweight even when you are severely underweight

Over time, anorexia nervosa can cause health problems such as:

Thinning of the bones (osteopenia or osteoporosis)

Mild anemia

Muscle wasting and weakness

Thin, brittle hair and nails

Dry, blotchy, or yellowish skin

Growth of fine hair all over the body

Severe constipation

Low blood pressure

Slowed breathing and pulse

Feeling cold all the time because of a drop in internal body temperature

Feeling faint, dizzy, or weak

Feeling tired all the time

Infertility

Damage to the structure and function of the heart

Brain damage

Multiorgan failure

Anorexia nervosa can be fatal. Some people with this disorder die of complications from starvation, and others die of suicide.

Some people with eating disorders may also have other mental disorders (such as depression or anxiety) or problems with substance use.

How is eating disorders diagnosed?

Because eating disorders can be so serious, it is important to seek help if you or a loved one thinks that you might have a problem. Your health care provider may use many tools to make a diagnosis:

A medical history, which includes asking about your symptoms. It is important to be honest about your eating and exercise behaviors so your provider can help you.

A physical exam

Blood or urine tests to rule out other possible causes of your symptoms

Other tests to see whether you have any other health problems caused by the eating disorder. These can include kidney function tests and an electrocardiogram (EKG or ECG).

What are the treatments for eating disorders?

Treatment plans for eating disorders are tailored to individual needs. You will likely have a team of providers helping you, including doctors, nutritionists, nurses, and therapists. The treatments may include:

Individual, group, and/or family psychotherapy. Individual therapy may include cognitive behavioral approaches, which help you to identify and change negative and unhelpful thoughts. It also helps you build coping skills and change behavioral patterns.

Medical care and monitoring, including care for the complications that eating disorders can cause

Nutrition counseling. Doctors, nurses, and counselors will help you eat healthy to reach and maintain a healthy weight.

Medicines, such as antidepressants, antipsychotics, or mood stabilizers, may help treat some eating disorders. The medicines can also help with the depression and anxiety symptoms that often go along with eating disorders.

Some people with serious eating disorders may need to be in a hospital or in a residential treatment program. Residential treatment programs combine housing and treatment services.

NIH: National Institute of Mental Health

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Eating disorders are serious mental health disorders. They involve severe problems with your thoughts about food and your eating behaviors. You may eat much less or much more than you need. Eating disorders are medical conditions; they are not a lifestyle choice. They affect your body's ability to get proper nutrition.

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Ages 6 - 18 years

Testing Time 30 - 40 minutes

Administration Individual

Product Code SERIES ( MR #059933 )

* Regional restriction: This item is only available for sale within Canada.

In evaluating children, it makes sense to look at more than academic ability and achievement. Social understanding, problem-solving skills, adaptability, sources of support, emotional adjustment, developmental issues--all of these things affect children's functioning at school, at home, and in the community. And all are measured by the Roberts-2.

This revision of the popular Roberts Apperception Test for Children helps you understand the whole child. The Roberts-2 provides useful descriptive information, telling you how well the child reads social cues, recognizes and solves interpersonal problems, copes with difficulties, makes use of social and emotional resources, and much more. This information is invaluable to any professional who is initiating an academic or behavioral intervention.

The test focuses on the child's social understanding as expressed in free narrative, reflecting both developmental and clinical concerns. The child's stories are recorded and then scored--according to objective criteria--for the presence or absence of specific characteristics. Norms, grouped by age, are based on a sample of more than 1,000 children aged 6 through 18, from all four U.S. Census regions. The sample is representative in terms of gender, ethnicity, and parental education.

The Roberts-2 helps you put the pieces together by not only providing a more complete picture of the child prior to intervention but also reflecting change following intervention. Standardized on nonreferred children, this test is an ideal way to assess developmental change and situational crises in nonclinical children.

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The Casebook was created to help clinicians integrate test scores and interpretation into school, special education, and clinical case reports.

Seventeen cases are described: 4 from normally developing children to help provide a grounded sense of typical variability and then 13 chosen to highlight issues for diagnostic categories that are among the most commonly evaluated in children and adolescents-Mild Mental Retardation, ADHD, Posttraumatic Stress Disorder, Autistic Disorder, Asperger's Disorder, Bipolar Disorder, Oppositional-Defiant Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, Conduct Disorder, Schizo-Affective Disorder, and Schizophrenia. Users can practice scoring cases (sample scoring by the author is provided), use profiles and interpretive discussion to better understand clinical issues in the areas treated, and learn how Roberts-2 results can inform evaluation reports and treatment plans.

Roberts-2 DVD Training Package

The Roberts-2 DVD Training Package provides everything you need to master the Roberts-2. Just watch the DVD and use the accompanying Workbook, Reference Materials, and Record Forms to practice coding, scoring, and interpretation.

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Mind Resources, a proudly Canadian company, provides resources for Teachers, Librarians, Counsellors, Speech-Language Pathologists, Occupational Therapists, Psychologists and other education associated professionals

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Adverse childhood experiences (ACEs) can have a tremendous impact on future violence victimization and perpetration, and lifelong health and opportunity. CDC works to understand ACEs and prevent them.

Adverse Childhood Experiences (ACEs) Prevention Strategy Plan [3 MB, 20 Pages]
This resource outlines CDC's specific goals and objectives for ACEs prevention and response. The goals and objectives aim to prevent ACEs before they happen, identify those who have experienced ACEs, and respond using trauma-informed approaches in order to create the conditions for strong, thriving families and communities where all children and youth are free from harm and all people can achieve lifelong health and wellbeing.

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Adverse childhood experiences (ACEs) can have a tremendous impact on future violence victimization and perpetration, and lifelong health and opportunity. CDC works to understand ACEs and prevent them. Adverse Childhood Experiences (ACEs) Prevention Strategy Plan [3 MB, 20 Pages] This resource outlines CDC's specific goals and objectives for ACEs prevention and response.

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A Review of Adverse Childhood Experiences

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A Review of Adverse Childhood Experiences

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as Factors Influential to Biopsychosocial

Development for Young Males of Color

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A Review of Adverse Childhood Experiences

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ADVERSE CHILDHOOD EXPERIENCES IMPLICATIONS FOR COUNSELORS

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ADVERSE CHILDHOOD EXPERIENCES IMPLICATIONS FOR COUNSELORS

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Compassion fatigue presents a paradox for counselors and others in the helping professions. As Alyson Carr, a licensed mental health counselor and supervisor in Florida, points out, it compromises their ability to do the very thing that motivated many of them to enter the field in the first place - empathically support those in pain.

Empathy and compassion are attributes those in the helping professions are particularly proud to possess and cultivate. Yet those same characteristics may leave some professionals more susceptible to becoming traumatized themselves as they regularly observe and work with those who are suffering.

Jennifer Blough provides counseling services to other helping professionals as owner of the private practice Deepwater Counseling in Ypsilanti, Michigan. She says many of her clients experience compassion fatigue. One of her former clients, an emergency room nurse, witnessed trauma daily. One day, the nurse treated a child who had suffered horrendous physical abuse, and the child died shortly after arriving at the hospital.

This incident haunted the nurse. She had nightmares and intrusive thoughts about the child's death and abuse. She started to isolate to the point that she had to step away from her job because she refused to leave her house. She couldn't even bring herself to call Blough. She just sent a text asking for help instead.

Blough, a licensed professional counselor (LPC) and certified compassion fatigue therapist, asked the nurse to come to her office, but the nurse said she was comfortable leaving her home only when accompanied by her dog. So, Blough told her to bring her dog with her to the session. That got the nurse in the door.

From there, Blough and the nurse worked together to help the client process her trauma. Blough also taught the client to recognize the warning signs of compassion fatigue so that she could use resiliency, grounding skills, relaxation, boundary setting, gratitude and self-compassion to help keep her empathy from becoming unmanageable again.
Defining compassion fatigue
"One of the most important ways to help clients who might be struggling with compassion or empathy fatigue is to provide psychoeducation," Blough says. "A lot of people don't even realize there's a name for what they're going through or that others are going through the same thing."

Blough, author of To Save a Starfish: A Compassion-Fatigue Workbook for the Animal-Welfare Warrior, didn't understand that she was experiencing compassion fatigue when she worked at an animal shelter and as an animal control officer before becoming a counselor. After she started feeling depressed, she decided that she was weak and unfit for her job and ultimately left the field entirely. It wasn't until she was in graduate school for counseling that she learned there was a name for what she had experienced - compassion fatigue.

According to the American Institute of Stress, compassion fatigue is "the emotional residue or strain of exposure to working with those suffering from consequences of traumatic events." This differs from burnout, which is a "cumulative process marked by emotional exhaustion and withdrawal associated with workload and institutional stress, not trauma-related."

Although compassion fatigue is the more well-known and widely used term, there is some debate about whether it is the most accurate one. Some mental health professionals argue that people can never be too compassionate. Instead, they say, what people experience is empathy fatigue.

In an interview with CT Online in 2013, Mark Stebnicki described empathy fatigue as resulting from "a state of psychological, emotional, mental, physical, spiritual and occupational exhaustion that occurs as the counselors' own wounds are continually revisited by their clients' life stories of chronic illness, disability, trauma, grief and loss."

April McAnally, an LPC in private practice in Austin, Texas, is among those who believe that people can't have too much compassion. Compassion involves having empathy and feeling what the other person does, but we have a screen - an internal boundary - that protects us, McAnally says. "Empathy, however, can be boundaryless," she continues. "We can find ourselves overwhelmed with what the other person is experiencing. ... So, what we actually become fatigued by is empathy without the internal boundary that is present with compassion."

As Blough puts it, "Empathy is the ability to identify with, or experience, another's emotions, whereas compassion is the desire to help alleviate suffering. In other words, compassion is empathy in action."

McAnally, a certified compassion fatigue professional, also suggests using the term secondary trauma. She finds that it more accurately describes the emotional stress and nervous system dysregulation that her clients experience when they are indirectly exposed to the trauma and suffering of another person or animal.
Symptoms and risk factors
Anyone can be susceptible to burnout, but compassion fatigue most often affects caregivers and those working in the helping professions, such as counselors, nurses, social workers, veterinarians, teachers and clergy.

Working in a job with a high frequency of trauma exposure may increase the likelihood of developing compassion fatigue, McAnally adds. For example, a nurse working in an OBGYN office may have a lower risk of developing compassion fatigue than would an emergency room nurse. Even though they both share the same job title, the impact and frequency of trauma is going to be higher in the ER, McAnally explains.

Counselors should also consider race/ethnicity and contextual factors when assessing for compassion fatigue. Racial injustices that members of marginalized populations regularly experience are sources of pervasive and ongoing trauma, McAnally notes. And unresolved trauma increases the likelihood of someone experiencing empathy fatigue, she adds.

Carr, an American Counseling Association member who specializes in complex trauma and anxiety, and Blough both believe the collective trauma resulting from the COVID-19 pandemic and exposure to repeated acts of racial violence and injustice could lead to collective compassion fatigue for all helping professionals (if it hasn't already).

McAnally, a member of the Texas Counseling Association, a branch of ACA, says the current sociopolitical climate has also affected the types of clients she is seeing, with more individuals who identify as activists and concerned citizens seeking counseling of late. She has found that these clients are experiencing the same compassion fatigue symptoms that those in the helping professions do.

Blough and Victoria Camacho, an LPC and owner of Mind Menders Counseling in Lake Hopatcong, New Jersey, say symptoms of compassion fatigue can include the following:

Feelings of sadness or depression

Sleep problems

Changes in appetite

Anger or irritability

Nightmares or intrusive thoughts

Feelings of being isolated

Problems at work

A compulsion to work hard and long hours

Relationship conflicts

Difficulty separating work from personal life

Reactivity and hypervigilance

Increased negative arousal

Lower frustration tolerance

Decreased feelings of confidence

A diminished sense of purpose or enjoyment

Lack of motivation

Issues with time management

Unhealthy coping skills such as substance use

Suicidal thoughts

There are also individual risk factors. According to Camacho, a certified compassion fatigue professional, individuals with large caseloads, those with limited or no support networks, those with personal histories of trauma or loss, and those working in unsupportive environments are at higher risk of developing compassion fatigue.

In fact, research shows a correlation between a lack of training and the likelihood of developing compassion fatigue. So, someone at the beginning of their career who feels overwhelmed by their job and lacks adequate training and support could be at higher risk for experiencing compassion fatigue, McAnally says.

One assessment tool that both Blough and Camacho use with clients is the Professional Quality of Life Scale, a free tool that measures the negative and positive effects of helping others who experience suffering and trauma. Blough says this assessment helps her better understand her clients' levels of trauma exposure, burnout, compassion fatigue and job satisfaction.
Regulating the body and mind
"Having an awareness of our emotions and experiences, especially in a mindful way, can serve as a barometer to help protect us against developing full-blown compassion fatigue," says Blough, a member of ACA and Counselors for Social Justice, a division of ACA.

Part of this awareness includes being mindful of one's nervous system and the physical changes occurring within one's body. When someone experiences compassion fatigue, their amygdala, the part of the brain involved in the fight-or-flight response, gets tripped a little too quickly, McAnally explains. So, their body may react as if they are in physical danger (e.g., heart racing, sweating, feeling panicky) even though they aren't.

If clients get dysregulated, McAnally advises them to use grounding techniques to remind themselves that they are safe. She will often ask clients to look all over the room, including turning around in their chairs, so they can realize there is nothing to fear at that moment. She also uses the 5-4-3-2-1 technique, in which clients use their senses to notice things around them - five things they see, four things they hear, three things they feel, two things they taste and one thing they smell.

Research has shown that practicing mindfulness for even a few minutes a day can increase the size of the prefrontal cortex - the part of the brain responsible for emotional regulation, McAnally adds.

Blough often uses the square breathing technique to ground clients and get them to slow down. She will ask clients to breathe deeply while simultaneously adding a visual component of making a square with their eyes. They breathe in for four seconds while their eyes scan left to right. They hold their breath for four seconds while their eyes scan up to down. They breathe out for four seconds while their eyes scan right to left. And they hold their breath for four seconds while their eyes move down to up.

Counselors can also teach clients to do a full body scan to regulate themselves, Blough and Camacho suggest. This technique involves feeling for tension throughout the body while visualizing moving from the head down to the feet. If the person notices tension in any area, then they stop and slowly release it.

Camacho once had a client lean forward and grab the armrest of the chair they were sitting in while talking. She stopped the client and asked, "Do you notice you are gripping the armrest? Why do you think you are doing that?"

The client responded, "I wasn't aware of it, but I find it comfortable. I feel like I'm grounding myself."

Camacho, an ACA member who specializes in posttraumatic stress disorder, trauma, and compassion fatigue in professionals who serve others, used this as a teachable moment to show the client how to ground themselves while also having relaxed muscles. She asked the client to release their grip on the chair and instead to lightly run their fingers across it and focus on its texture.

Carr finds dancing to be another useful intervention. "Engaging in dancing and moving communicates to our brains that we are not in danger. [It] allows us to develop and strengthen affect regulation skills as well as have a nonverbal, integrated body-mind experience," she explains.
Creating emotional boundaries
Setting boundaries can be another challenge for helping professionals. Blough says many of her clients report feeling guilty if they say "no" to a request. They often feel they have to take on one more client or take in one more animal. But she asks them, at whose expense?

Blough reminds clients that saying "no" or setting a boundary just means saying "yes" to another possibility. For example, if a client wants to schedule an appointment on Thursday night at the same time that the therapist's child has a soccer game, then telling the client "no" just means that the therapist is saying "yes" to their family and to their own mental health.

Blough and McAnally recommend that people create routines to help themselves separate work from home. For example, clients and counselors alike could listen to an audiobook or podcast during their commute home, or they could meditate, take a walk or even take a shower to signify the end of the workday, Blough suggests. "Anything that helps them clear their head and allows them to be fully present for themselves or their families," she adds.

People can also establish what Carr calls an "off switch" to help them realize that work is over. That action might involve simply shutting the office door, washing one's hands or doing a stretch. At the end of the workday, Carr likes to put her computer in a different room or in a drawer so that it is out of sight and mind. Then, she takes 10 deep breaths and leaves work in that space.
Exercising self-compassion
"Because a lot of helping professionals are highly driven and dedicated, they tend to have unrealistic expectations and demand a lot from themselves, even to the point of depletion," Blough says. "Having low levels of self-compassion can lead to compassion fatigue, particularly symptoms associated with depression, anxiety and posttraumatic stress disorder."

In other words, self-compassion is integral to helping people manage compassion fatigue. "Self-criticism keeps our systems in a state of arousal that prevents our brains from optimal functioning," Carr notes, "whereas self-compassion allows us to be in a state of loving, connected presence. Therefore, it is considered to be one of the most effective coping mechanisms. It can provide us with the emotional resources we need to care for others, help us maintain an optimal state of mind, and enhance immune function."

According to Kristin Neff, an expert on self-compassion, caregivers should generate enough compassion for themselves and the person they are helping that they can remain in the presence of suffering without being overwhelmed. In fact, she claims that caregivers often need to focus the bulk of their attention on giving themselves compassion so that they will have enough emotional stability to be there for others.

People in the helping professions can become so focused on caring for others that they forget to give themselves compassion and neglect to engage in their own self-care. Blough often asks clients to tell her about activities that they enjoy - ones that take their mind off work, help them relax and allow them to feel a sense of accomplishment. Then she asks how often they engage in those activities. Clients often tell her, "I used to do it all the time before I became a professional caregiver."

She reminds them that they can help others only if they are also taking care of themselves. That means they need to take time to engage in activities that relax and recharge them; it isn't a choice they should feel guilty making.
Self-regulating in session
As helpers, counselors are likely to experience symptoms of compassion fatigue at some point. This is especially true for clinicians who frequently see clients who are dealing with trauma, loss and grief.

For McAnally, that experience came early in her career. During practicum, she had a client with a complex trauma history who couldn't sleep at night. In turn, McAnally found herself waking up in the middle of the night, worrying about the client. She knew this was a warning sign, so she reached out to her supervisor, who helped her develop a plan to mitigate the risk of compassion fatigue.

It almost goes without saying that counselors should take the advice they give to their own clients: They should establish a self-care routine. They should seek their own counseling and support. They should set boundaries and find ways to recharge outside of work. And they should exercise self-compassion.

But counselors also need to find ways to self-regulate during sessions. "If you are tense and you're hearing all of these heavy stories, you're at a much greater risk of being vicariously traumatized," Blough says. Self-regulation can provide a level of protection from that occurring, she notes.

Blough often uses the body scan technique while she is in session. Doing this, she can quietly relax her body without it drawing the attention of her clients. In addition, as she teaches relaxation skills to her clients, she does the skills with them. For example, she slows her own breathing while teaching clients guided breath work. That way, she is relaxing along with them.

Likewise, McAnally has learned to be self-aware and regulate her nervous system when she is in session. If she notices her heart rate accelerating and her stomach clinching when a client is describing a painful or traumatic event, then she grounds herself. She orients herself by wiggling her toes and noticing what it feels like for her feet to be touching the ground. She also looks around the room to remind her brain that she is safe.

McAnally also uses internal self-talk. She will think, "I'm OK right now." As with the body scan, this is a subtle action that clinicians can take to ground themselves without the client even being aware that they are doing it.
Helping the helpers during COVID-19
Recently, Carr received a text from a counseling mentor who has been practicing for 40 years that said, "I am falling apart. I am lost. I don't know what to do, but sending a text to someone I trust felt right. Write or call when you can."

Carr quickly reached out, and her colleague said he was experiencing a sense of hopelessness that he hadn't in many years. He worried about his clients and feared he wasn't doing everything he could for them. He was also anxious about finances; several of his clients had become unemployed because of the COVID-19 pandemic, so he started seeing them pro bono. All of this was taking a toll on him personally and professionally.

Before the pandemic, McAnally managed her compassion fatigue symptoms in part by checking in with other therapists who worked down the hall from her office and by participating in in-person consultation groups. Now that she is working from home full time because of the pandemic, she says that she has to be more intentional about practicing self-care and accessing support. She calls her colleagues to check in, practices mindfulness, and schedules breaks to go outside and play with her dog.

Even when counselors recognize that they need help, they can encounter barriers similar to those their clients face. For instance, they may not be able to find in-network providers, and only a small portion of the hourly rate may be covered by their insurance. This problem made Carr pose some questions: "Who is helping the helpers right now? How can we take care of others if we aren't able to more easily take care of ourselves?"

Then she decided to take action. She created Counseling for Counselors, a nonprofit organization dedicated to raising awareness about the emotional and psychological impact on mental health providers during a time of collective trauma. The organization's aim is to generate funding that would allow self-employed licensed mental health professionals in need of treatment to more easily access those services.

"Although the heightened state of anxiety around the pandemic may have exposed this critical need, the demand for quality, affordable mental health care for counselors is ongoing," Carr says. "Counselors are not immune to trauma and, now more than ever, licensed mental health professionals need access to mental health services in order to effectively treat the populations we serve and to continue to play an instrumental part in contributing to the well-being of society at large."
Fostering compassion satisfaction
People in the helping professions often feel guilty or ashamed about struggling with compassion fatigue. They sometimes believe they should be immune or should be able to find a way to push through despite their symptoms. But that isn't the case.

"I think the biggest takeaway when it comes to compassion fatigue is that it's a normal, almost inevitable consequence of caring for and helping others. It's not a character flaw or a sign of weakness. It's not a mental illness. It affects the best and brightest and those who care the most," Blough says.

For that matter, compassion fatigue isn't something you "have" or "don't have," she adds. Instead, it operates on a spectrum, which is why it is so important for helping professionals to be aware of its warning signs and symptoms.

Blough acknowledges that compassion fatigue is always present in some form for her personally. She often manages it well, so it just simmers in the background. But sometimes it boils over. When that happens, she knows to regulate herself, to increase her self-care and to get support.

It is easy for a negative experience to overshadow a helping professional's entire day and push aside any positive aspects. That's why Blough and McAnally both recommend setting aside time daily to list three positive things that happened at work. A counselor or other helping professional could focus on the joy they felt when they witnessed an improvement in their client that day or when they witnessed the "aha!" moment on their client's face.

Blough often advises clients to journal or otherwise reflect on these positive experiences before they go to bed because it can help prevent rumination and intrusive thoughts that may disrupt sleep. Celebrating these "little victories" will help renew their passion for their job, she adds.

As Blough points out, "Empathy can definitely lead to compassion fatigue, but if properly managed, it can also foster compassion satisfaction, which is the antithesis of compassion fatigue. It's the joy you get from your work."
****
Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.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.

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Grappling with compassion fatigue - Counseling Today

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Counselors and other helping professionals who are regularly exposed to others' trauma almost invariably find themselves confronting symptoms of compassion fatigue at some point during their careers.

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Screening for Adverse Childhood Experiences and Trauma

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Screening for Adverse Childhood Experiences and Trauma

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The National Child Traumatic Stress Network

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Understanding Who is at Risk

The development of secondary traumatic stress is recognized as a common occupational hazard for professionals working with traumatized children. Studies show that from 6% to 26% of therapists working with traumatized populations, and up to 50% of child welfare workers, are at high risk for secondary traumatic stress or the related conditions of PTSD and vicarious trauma. Any professional who works directly with traumatized children, and is in a position to hear the recounting of traumatic experiences, is at risk for secondary traumatic stress. That being said, risk appears to be greater among women and among individuals who are highly empathetic by nature or have unresolved personal trauma. Risk is also higher for professionals who carry a heavy caseload of traumatized children; are socially or organizationally isolated; or feel professionally compromised due to inadequate training. Protecting against the development of secondary traumatic stress includes factors such as longer duration of professional experience and the use of evidence-based practices in the course of providing care.

Clearly, client care can be compromised if the therapist is emotionally depleted or cognitively affected by secondary trauma. Some traumatized professionals, believing they can no longer be of service to their clients, end up leaving their jobs or the serving field altogether. Several studies have shown that the development of secondary traumatic stress often predicts that the helping professional will eventually leave the field for another type of work.

Strategies for Prevention and Intervention

A multidimensional approach to prevention and intervention-involving the individual, supervisors, and organizational policy-will yield the most positive outcomes for those affected by secondary traumatic stress. The most important strategy for preventing the development of secondary traumatic stress is the triad of psychoeducation, skills training, and supervision. As workers gain knowledge and awareness of the hazards of indirect trauma exposure, they become empowered to explore and utilize prevention strategies to both reduce their risk and increase their resiliency to secondary stress. Preventive strategies may include self-report assessments, participation in self-care groups in the workplace, caseload balancing, use of flextime scheduling, and use of the self-care accountability buddy system. Proper rest, nutrition, exercise, and stress reduction activities are also important in preventing secondary traumatic stress.

Although evidence regarding the effectiveness of interventions in secondary traumatic stress is limited, cognitive-behavioral strategies and mindfulness-based methods are emerging as best practices. In addition, caseload management, training, reflective supervision, and peer supervision or external group processing have been shown to reduce the impact of secondary traumatic stress. Many organizations make referrals for formal intervention from outside providers such as individual therapists or Employee Assistance Programs. External group supervision services may be especially important in cases of disasters or community violence where a large number of staff have been affected.

Strategies to Build Resiliency and Address STS

Provide adequate clinical supervision, including reflective supervision

Maintain trauma caseload balance

Support workplace self-care groups

Enhance the physical safety of staff

Offer flextime scheduling

Incorporate STS training into EBP training for clinical staff

Create external partnerships with STS intervention providers

Train organizational leaders and non-clinical staff on STS

Train organizational leaders on organizational implementation and assessment

Provide ongoing assessment of staff risk and resiliency

Use supervision to address STS

Increase self-awareness of STS

Maintain healthy work-life balance

Exercise and good nutrition

Practice self-care

Stay connected

Develop and implement plans to increase personal wellness and resilience

Continue individual training on risk reduction and self-care

Use Employee Assistance Programs or counseling services as needed

Participate in a self-care accountability buddy system

Worker Resiliency in Trauma-Informed Systems: Essential Elements

Both preventive and interventional strategies for secondary traumatic stress should be implemented as part of an organizational risk-management policy or task force that recognizes the scope and consequences of the condition. The following concepts are essential for creating a trauma-informed system that will adequately address secondary traumatic stress. Specifically, the trauma-informed system must:

Recognize the impact of secondary trauma on the workforce

Recognize that exposure to trauma is a risk of the job of serving traumatized children and families

Understand that trauma can shape the culture of organizations in the same way that trauma shapes the world view of individuals

Understand that a traumatized organization is less likely to effectively identify its clients' past trauma or mitigate or prevent future trauma

Develop the capacity to translate trauma-related knowledge into meaningful action, policy, and improvements in practices

Be integrated into direct services, programs, policies, and procedures, staff development and training, and other activities directed at secondary traumatic stress

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The development of secondary traumatic stress is recognized as a common occupational hazard for professionals working with traumatized children. Studies show that from 6% to 26% of therapists working with traumatized populations, and up to 50% of child welfare workers, are at high risk for secondary traumatic stress or the related conditions of PTSD and vicarious trauma.

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Trauma and Burnout Counselors in Training

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Trauma and Burnout Counselors in Training

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Reflection Reference Guide for Mental Health Disorders 

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Reflection Reference Guide for Mental Health Disorders 

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Creating our mental health reference guide was an eye-opening journey for me. As we gathered information on depression, psychosis, substance use, and eating disorders, I realized the profound impact these issues can have on individuals. Breaking down complex concepts into simple terms for the guide allowed me to see the importance of clear communication in providing support.

Researching each topic made me more aware of the signs and symptoms, which I believe is crucial for anyone wanting to help others. The guide we compiled serves as a valuable resource, not just for us but for anyone seeking information on mental health.

It's empowering to know that we've created a tool that can potentially make a difference in someone's life by offering straightforward and accessible information about mental health challenges.

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Artifact: Reference Guide for Mental Health

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Artifact: Reference Guide for Mental Health

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Reflection  Developmental Discussion on Trauma

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Reflection  Developmental Discussion on Trauma

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Reflecting on the documentary "Murder to Mercy: The Cyntoia Brown Story," I've learned valuable lessons that directly apply to my future role as a counselor. Firstly, Cyntoia's journey highlighted the profound impact of childhood trauma on a person's life choices and mental health. This taught me the importance of approaching clients with empathy and understanding, especially when they carry past challenges.

The documentary also made me realize the significance of considering cultural factors in counseling. Cyntoia, as an African American woman, faced unique challenges within the criminal justice system. This reinforced the need for me, as a future counselor, to be culturally competent, understanding the broader social issues that can contribute to a person's trauma.

Additionally, the collaboration between legal and healthcare professionals in Cyntoia's case emphasized the importance of a holistic approach to trauma. This takeaway aligns with my role, highlighting the need for comprehensive support and collaboration with different professionals to address the complexities of trauma effectively.

Overall, I've learned that empathy, cultural competence, and collaboration are crucial in helping individuals like Cyntoia navigate and heal from their traumatic experiences. This documentary has deepened my understanding and reminded me of the responsibility I'll have as a counselor to provide thoughtful and inclusive support for my future clients.

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Artifact Developmental Discussion on Trauma

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Artifact Developmental Discussion on Trauma

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Exploring Psychological First Aid has taught me essential aspects of providing immediate support after disasters or traumatic events. I discovered that PFA, with its eight core actions like safety and connection, is flexible and doesn't assume everyone will have severe mental health issues. This aligns perfectly with my counseling philosophy of tailoring support to individual needs.

Learning that PFA can be applied in diverse settings, from shelters to emergency departments, fits well with my goal of being an adaptable counselor. The emphasis on safety, comfort, and practical assistance reinforces how I can play a crucial role in providing immediate help and support to individuals and communities during challenging times. Overall, this section has given me practical tools and insights that will shape my role as a counselor, emphasizing the importance of personalized and versatile support.

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Artifact: Psychological First Aid Online Certificate

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Artifact: Psychological First Aid Online Certificate

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Reflection: Crisis Prevention and Threat Assessment

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Reflection: Crisis Prevention and Threat Assessment

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Completing the crisis prevention and threat assessment assignment for domestic violence and child protection has provided me with crucial insights. Recognizing that crises extend beyond large-scale incidents to include personal traumas highlighted the need for strategic planning. Understanding the necessity of a comprehensive prevention and threat assessment plan, along with the role of threat assessment teams in addressing at-risk individuals, emphasized the broad relevance of these measures. Learning that my expertise as a mental health professional is a valuable asset to these teams reinforces my commitment to fostering emotional well-being. Realizing the ongoing effort required for prevention underscores the importance of continuous advocacy for practices supporting sound mental health. Overall, this assignment has deepened my understanding of crisis prevention, shaping my approach as a counseling professional committed to creating safer and more supportive environments.

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Artifact:  Crisis Prevention and Threat Assessment

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Artifact:  Crisis Prevention and Threat Assessment

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Completing the ABC model assignment for Melynda's case provided valuable insights into the intricacies of counseling. In the process of achieving a relationship, I grasped the significance of employing attentive communication and empathetic techniques to establish trust. The examples demonstrated how these skills contribute to creating a conducive environment for clients to openly share their concerns. Analyzing the case through the ABC model's lens in the second part shed light on the multifaceted nature of Melynda's challenges. It underscored the need for a holistic approach in addressing her physical, emotional, social, and cognitive struggles, revealing the interconnectedness of these aspects. This section deepened my understanding of the comprehensive role counselors play in unraveling complex client issues.

The commitment to action section prompted critical reflection on practical steps for both the counselee and counselor. It reinforced the proactive nature of counseling, emphasizing the counselor's role in guiding clients toward positive change. This assignment served as a reminder of the dynamic and collaborative nature of the counseling process. As I step into the role of a counselor, I carry forward the structured framework of the ABC model, ensuring a systematic and thoughtful approach to client assessment and intervention.

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As a professional counselor, it is crucial for me to adhere to the ethical codes outlined in the ACA Code of Ethics. These ethical codes serve as a guide for my daily practice and decision-making processes. The fundamental principles of professional ethical behavior include autonomy, nonmaleficence, beneficence, justice, fidelity, and veracity. These principles form the foundation for ethical behavior and decision-making in counseling.

Furthermore, the code addresses the importance of confidentiality and privacy in counseling relationships. It outlines the responsibilities of counselors in maintaining confidentiality and respecting the privacy of clients, which is essential in building trust and fostering a therapeutic relationship.

In situations where ethical responsibilities conflict with laws or regulations, counselors are expected to prioritize the well-being of the client while also adhering to legal requirements. This demonstrates the code's relevance to my role as a counselor, as it guides me in navigating complex ethical dilemmas and ensuring that my actions are in the best interest of my clients while also complying with legal obligations.

Overall, the ACA Code of Ethics is applicable to my role as a counselor as it provides a comprehensive framework for ethical practice, guides decision-making processes, and upholds the values and principles essential for maintaining professional conduct in the field of counseling.

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Crisis Intervention Issues and Challenges 

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Crisis Intervention Issues and Challenges 

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In my role as a counselor, the referral process plays a crucial role in ensuring that clients receive the most appropriate and effective support. When faced with issues or challenges that fall outside the scope of my expertise or the services I can provide, it is ethically responsible to guide clients toward specialized professionals or resources. Referrals within my scope of practice involve a careful and collaborative approach.

Firstly, I assess the client's needs and the nature of their concerns. If it becomes evident that a particular aspect of their situation requires specialized expertise, such as medical or legal advice, I discuss the potential benefits of seeking assistance from a qualified professional in that field. It is essential to communicate openly and transparently with the client, ensuring they understand the reasons for the referral and the potential benefits it may bring to their overall well-being.

I maintain a network of trusted and competent professionals or organizations to whom I can refer clients. This network is built on mutual respect, collaboration, and a shared commitment to client welfare. Additionally, I provide ongoing support and guidance during the referral process, ensuring a smooth transition and helping the client navigate any concerns or uncertainties they may have about seeking additional assistance. Overall, the referral process is a collaborative effort aimed at ensuring clients receive comprehensive and specialized care beyond the scope of my practice.

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Local Emergency and Non-emergency support services 

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Local Emergency and Non-emergency support services 

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**Emergency Services:**

1. **911:** Universal emergency number for immediate assistance in life-threatening situations.

2. **National Suicide Prevention Lifeline:** 1-800-273-TALK (1-800-273-8255) - Confidential support for individuals in crisis.

**Non-Emergency Support Services:**

1. **Crisis Text Line:** Text "HELLO" to 741741 - Confidential text-based support for those in crisis.

2. **Texas Health and Human Services Commission:** 2-1-1 - Information and referral helpline for health and human services.

3. **Texas Department of State Health Services - Mental Health Crisis Hotline:** 1-800-273-8255 (Press 1) - 24/7 crisis support for mental health issues.

4. **National Alliance on Mental Illness (NAMI) Texas:** 1-800-950-NAMI (6264) - Support and information on mental health conditions.

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Understanding cultural competence is crucial not only in addressing the traumas individuals share but also in navigating the broader landscape of social issues. It's about recognizing systemic challenges and ensuring that my counseling services are responsive to the diverse backgrounds of my clients. Overall, cultural competence is the foundation for fostering trust, building connections, and providing effective support that resonates with the unique experiences of each person seeking counseling.

Reflecting on our discussions and the impactful documentary "Murder to Mercy: The Cyntoia Brown Story," cultural competence emerges as a cornerstone when delivering responsive counseling services. In my journey toward becoming a counselor, it's clear that cultural competence goes beyond recognizing differences – it's about understanding, respecting, and tailoring support to meet the diverse needs of each individual.

Watching Cyntoia's story reinforced the importance of cultural competence in addressing systemic issues that intersect with mental health and trauma. As I embark on my role, it's vital to create a safe and inclusive space for clients from diverse backgrounds, ensuring they feel understood and supported. Cultural competence, in essence, becomes the key to fostering genuine connections and facilitating healing journeys for individuals facing trauma.