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This was my first experience working in a group and using google docs/slides. I struggled with formatting the slide, but figured it out. I asked for help. I learned a lot about crisis plans in the group project. There is a lot that goes into it. I had some idea because I have talked to people that helped in various crises.

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Reflections on ABC Model of Intervention

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Reflections on ABC Model of Intervention

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Working through the ABC model was very helpful. I had a client earlier in the week spiraling due to losing his last friend in a police shooting. I did not feel I was effectively able to help the youth. I learned that some of what I did was listed in the resources and other ways I could have handled the situation. I often deal with clients in crisis as a substance use counselor. I have had clients in the past who are in crisis more than not. I am looking forward to putting some of what I learned into action, as well as sharing it with my interns.

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I felt that the Psychological First Aid course was very informative. One of my goals is to help in a crisis by offering 5NP Auricular Acupuncture for stress. I belong to an organization that has been to several natural disasters, as well as mass shootings and have been invited. I feel that this course gave me a better idea of what to expect. I was able to offer coping skills in a moment of crisis with a client while also modeling calm. One thing I might struggle with is just focusing on what is most important. However, I have been doing referrals since before I was a counselor in my role as peer support specialist. I enjoy developing relationships with those I work with, so it would be strange developing that relationship for only a shift.

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Hello all,

I am in the Mental Health and Wellness program to complete the education requirements for Licensed Professional Counselor (LPC) and to gain more information and practice to help others. My current role is Program Supervisor for Substance Use Services treatment program in a juvenile justice facility. I am a Licensed Chemical Dependency Counselor (LCDC) that supervises LCDC-Interns.

My main reason for choosing Intro to Trauma as my first course was to learn how to be more effective with my clients as they have had a lot of trauma. Prior to starting this class, I recognized that I had been under a lot of stress this year and noticed trauma responses being triggered, therefore I am looking forward to learning more to help myself so that I can be more effective with others.

A goal for this class is to be more aware of trauma responses in the interns I supervise and the youth I work with, as well as more awareness personally and to be able to offer more resources.

A goal that I have had for several years has been to bring more nature into my counseling practice, whether as an LCDC or LPC.

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Reflection on Developmental Discussion on Trauma

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Reflection on Developmental Discussion on Trauma

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This was very helpful. I work in a trauma-informed agency with youth that have a lot of trauma. I have not been very effective as counselor and had been experiencing a lot of stress. I was able to work through some of that and gain some insight on how to approach the youth I work with, as well as the interns I supervise. I also gained some information on the agency I work for and how that will apply to my position. I have trained in trauma-informed care in the past and utilized the training. I am not sure what happened when I began my position, but it was great to get the reminders of how to show up trauma-informed.

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Reflection on Reference Guide for Mental Health Disorders

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Reflection on Reference Guide for Mental Health Disorders

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I found that the DSM-V-TR is my source for mental health disorders. In my last position, I worked in insurance-driven treatment and even though diagnosing is out of my scope of practice, I still used the DSM to discuss clients with my team. The DSM always overwhelms me. I feel that at some point in my life, I could have been diagnosed with many of the disorders. In the past, I used the DSM-V. I found some of the changes in the TR interesting and more informative.

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Reference Guide for Mental Health Disorders

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Reference Guide for Mental Health Disorders

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In my current role, I work with youth who are incarcerated, many of them for murder, and many have sentences that are more than 10 years. They will transfer to adult parole upon their 19th birthday if they do not transfer to an adult correctional facility.

One thing I hear the youth say is that they did not mean to pull the trigger or kill the person. I would like to know how the trauma of killing someone coupled with being told that they are a menace to society and being removed from society affects them. Yes, I have heard several of them say that they have been told by their judges or others that they are a menace to society.

I want to be able to bring more happiness into the youth's life that I work with. I am blessed to work for an agency that has implemented a more trauma-informed philosophy.

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Many people turn to yoga for stress and anxiety relief. Learn how yoga for anxiety works, plus some basic poses to get started.

Many people living with anxiety use a combination of methods to manage their symptoms, including therapy, lifestyle changes, and often, alternative treatments like yoga.

Anxiety disorders affect more than 40 million ( 18.1%) U.S. adults over age 18 each year. Anxiety is treatable, but only around 40% of people are receiving treatment.

Over the years, research studies have shown that yoga can help relieve stress and anxiety. It works by soothing an overactive nervous system, relaxing both the mind and body.

The 2021 State of Mental Health in America Report shows that the number of people seeking help for their anxiety disorders has skyrocketed during the COVID-19 pandemic, so right now, the need for effective anxiety management is especially high.

Yoga is an accessible, adaptable practice you can do from the comfort of your own home. The practice can be modified to accommodate bodies of all types, abilities, and backgrounds.

If you live with chronic anxiety, your nervous system - specifically your sympathetic nervous system, also known as the fight, flight, or freeze system - is operating in overdrive. This means your body has a heightened reaction to perceived threat, leading to anxiety responses such as agitation, stress, and heart palpitations.

As a consequence, you also have an underactive parasympathetic nervous system, or your rest-and-digest system. This system regulates your physiological functions, like heart rate and digestion.

According to research, stimulating the vagus nerve - a key part of the rest-and-digest system - is key to modulating the fight, flight, or freeze stress response.

One way to stimulate the vagus nerve is through practicing yoga.

Yoga poses stimulate the vagus nerve

"The parasympathetic nervous system helps us to feel safe and calm, and various aspects of yoga help to stimulate it," says Valerie Knopik, PhD, a psychologist, professor at Purdue University, and yoga instructor at Yoga Medicine based in Indianapolis, Indiana.

Yoga stimulates the vagus nerve by enhancing interoception, or how we perceive sensations arising in the body.

"Practices that increase interoception enable a person to distinguish between safe and fearful or dangerous situations," Knopik says.

Yoga also increases vagal tone, which means your body is able to relax sooner after stress. Knopik says that increasing your vagal tone could reduce the symptoms of nervous system dysfunction, such as feelings of anxiety.

Yoga offers many opportunities to experience interoception and stimulate the vagus nerve. Through physical movement, you can explore sensation as it arises in your body by developing awareness of what muscles are being challenged, stretched, or released.

Pranayama breath work connects the mind and body

Yoga, which means union, connects the mind and body through the breath. Pranayama, a Sanskrit term that describes how the breath is regulated during yoga, is a powerful tool for calming the sympathetic nervous system.

As Knopik explains, pranayama is a voluntary breathing practice that sends messages to the brain via the respiratory system.

"Certain breath practices can help with feelings of relaxation and calm, such as the long exhale or diaphragmatic breathing, primarily through stimulation of the vagus nerve and the vagus nerve's connection to heart rate variability," Knopik says.

But not all forms of pranayama may be appropriate for anxiety.

"Some breath practices are meant to be invigorating and more stimulating, such as Kapalabhati ('Breath of Fire'), which can stimulate the sympathetic nervous system and not the parasympathetic nervous system," she says.

Depending on the severity of your anxiety symptoms, pranayama that encourages deeper, steadier breathing patterns, such as Ujjayi breath, may be more suitable.

Meditation promotes relaxation

"Meditation is perhaps the most interoceptive practice of all and encourages us to watch our thoughts," Knopik says. "Practicing meditation can help with self-regulation and mindfulness, which helps to keep us in our bodies and out of our thoughts."

Yoga poses (asanas) are a vehicle for exploration of the present moment. Observing your thoughts that arise during mindful movement is a practice of building awareness. This can promote relaxation.

A 2012 research review suggests that meditative therapies (i.e., meditation, yoga, qigong, etc.) are effective tools for alleviating anxiety symptoms.

The best yoga poses for anxiety relief are the ones that feel good for your body and help you get grounded and find a sense of calm.

On some days, slower practices like Hatha, or gentle practices like restorative or Yin yoga, might be exactly what you need to clear your mind. Practices like these can stimulate the body's relaxation response.

On other days, faster-paced classes, such as Vinyasa, could be just as effective. Movement can help release stress and anxiety.

High anxiety levels can mean that you're not always able to begin a yoga practice with relaxation techniques.

"When there is high sympathetic nervous system activity, the mind is likely racing, which would make still postures (seated or otherwise) distressful," Knopik says.

In Knopik's experience, those who benefit from faster-paced styles of yoga tend to have developed the necessary breathwork, self-regulation, and interoception skills to remain calm and centered throughout the practice.

Without these skills, faster-paced yoga classes could be overstimulating for some people with anxiety.

"Still postures or practices need to come after some aspect of movement where nervous or anxious energy is released and individuals feel calmer," Knopik says.

More experienced practitioners may find that standing and balancing postures can help with feeling grounded and present, but can be more helpful following movement.

Seated Neck Stretch

To perform Seated Neck Stretch:

1. Begin in Easy Pose (Sukhasana), also known as a comfortable cross-legged seat.

2. Inhale and reach your right arm overhead.

3. Exhale to place your right palm over your left ear as you gently draw your head to the right and chin toward your chest.

4. Hold for 3-5 cycles of breath and release. Switch sides.

5. Optional: Place a blanket under your bottom for support, or perform this stretch seated in a chair.

Cat Pose

To perform Cat Pose (Marjaryasana):

1. Cat and Cow Pose are performed together.

2. Come to a tabletop position on your hands and knees.

3. Inhale and press into your palms, round your spine like a cat, and drop your chin, crown, and tailbone.

4. Move into Cow Pose (see below) on the exhale.

Cow Pose

To perform Cow Pose (Bitilasana):

1. From Cat Pose, exhale and drop your belly, broaden through your chest, and extend the crown of your head and tailbone upward.

2. Rotate your inner elbows forward and avoid collapsing your shoulders.

3. Inhale back to Cat Pose, and exhale to Cow.

4. Repeat the movement pattern for 5-7 cycles of breath, synchronizing each move with your breath.

Extended Puppy Pose

To perform Extended Puppy Pose (Uttana Shishosana):

1. From a tabletop position, shift your hands a little forward and knees back.

2. Press into your palms as you reach your bottom back.

3. Allow your forehead to touch your mat, and try to relax your neck and shoulders.

4. Breathe deeply in and out through your nose for 5-7 cycles of breath.

5. Optional: Place a blanket beneath your knees and shins for additional support. Or, depending on the level of your experience, you can tuck your toes under and reach your bottom up and back to come to Downward-Facing Dog (Adho Mukha Svanasana).

Half Splits

To perform Half Splits (Ardha Hanumanasana):

1. From a tabletop position, step your right foot forward into a lunge position, and tuck your left toes under. Your fingertips should be about shoulder-width distance apart, framing your front foot.

2. Slide your right foot forward until your leg is mostly straight.

3. Dig into your heel to flex your toes upward as you shift your hips slightly back to stretch your right hamstring muscle.

4. Hold for 3-5 deep breaths, then return to tabletop position. Switch sides.

5. Optional: Place your hands on yoga blocks and keep a micro-bend in your front knee. You can also soften your chin toward your chest and allow your torso to fold toward your front knee.

Seated Forward Bend

To perform Seated Forward Bend (Paschimottanasana):

1. From tabletop position, shift your bottom back toward your heels, and extend your legs out long in front of you.

2. Remove extra flesh from your sitting bones so you can feel them anchoring into your mat.

3. Sit up tall, flex your feet, and inhale to reach your arms overhead.

4. Exhale to hinge at your hips as you begin to fold your torso toward your thighs.

5. Your hands can be placed on the outsides of your thighs, calves, ankles, or feet, depending on your range of motion.

6. Drop your chin to your chest to release the back of your neck.

7. Breathe deeply, softening with each exhale, remaining here for 5-7 cycles of breath.

8. Optional: Place a rolled up blanket underneath the backs of your knees for support, especially if your hamstrings are tight.

Constructive Rest

To perform Constructive Rest (Savasana Variation Bent Legs):

1. Lie on your back with your knees bent, feet on the floor, and arms by your sides with your palms face up.

2. Adjust the placement of your feet and arms until you feel comfortable and supported.

3. Find a neutral spine by allowing for a slight curvature at the back of your neck (cervical spine) and your lower back (lumbar spine).

4. Allow for space between your chin and chest, and send your arms out a little wider.

5. Breathe deeply. This is an excellent pose for releasing your psoas muscle and resetting your nervous system. You can remain here for a few minutes or longer.

6. Optional: Widen your feet to the outside edges of your mat, and let your knees knock in toward each other.

Supine Spinal Twist

To perform Supine Spinal Twist (Supta Matsyendrasana):

1. From Constructive Rest, widen your feet to the outside edges of your mat (if they're not already there).

2. Take a deep breath in, then exhale to let both knees fall over to the right, keeping your legs staggered.

3. Gently turn your chin to the left to deepen the twist.

4. Breathe deeply into your belly, lengthening the exhales.

5. After 5-7 cycles of breath, inhale to bring your knees and chin back to their starting position, adjusting your hips if needed.

6. Exhale to drop your knees to the left, and turn your chin to the right.

7. Optional: Stack or wrap the legs.

Corpse Pose (Savasana)

To perform Corpse Pose (Savasana):

1. From Constructive Rest, extend your legs out long and adjust the position of your arms until you're comfortable.

2. Consider supporting this final resting pose with yoga props to help you feel grounded and safe. For example, you can place a folded blanket over your abdomen and another behind your head.

3. If your mind is still racing, keep your Savasana on the shorter side (1-2 minutes). If it's uncomfortable to close your eyes, keep them open and find something overhead to affix your gaze, and focus on your breathing.

4. Optional: Listen to a guided meditation or ambient music.

While many people practice yoga to relieve symptoms of stress and anxiety disorders, it should not always serve as a replacement for clinical treatment, especially when a person is experiencing panic attacks or has a severe anxiety disorder diagnosis.

While proponents may claim the "yoga high" experienced during a yoga practice can offer relief from stress and anxiety, it's important to keep in mind that this emotional state is often fleeting.

In fact, a 2021 study suggests that in some cases, mindfulness practices can backfire and actually cause anxiety to spike.

While yoga can be a healthy coping mechanism, relying on it to resolve a psychological condition is not an effective long-term solution on its own.

"Anything can become unhealthy when done to extremes," Knopik says. "Our bodies thrive with variability, both from a physiological perspective and an emotional perspective. Finding multiple ways to relieve anxiety would be most beneficial to most individuals. From a stress management perspective, the more resources we have available, the better."

A 2018 research review supports the practice of yoga for relief from symptoms associated with anxiety disorders, but more clinical studies are still needed before yoga should be used as a first-line approach to treatment.

Talk with your doctor or mental health professional to find out whether yoga is right for you. When practiced in conjunction with psychotherapy, medication, or both, yoga may be a wonderful complement to your treatment.

Yoga can enhance self-efficacy, which can be a valuable tool for calming minds and bodies to manage anxiety.

If you're ready to begin your yoga journey and explore the power of the present moment, the safest and most effective way to learn is in person with a certified yoga instructor.

If you don't have access to a yoga studio, most studios now stream classes online. Of course, countless instructional videos are available on YouTube at no cost. For example, this 20-minute yoga practice for anxiety from Yoga with Adriene is a great place to get started.

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Yoga for Anxiety: Why it Works and 9 Poses to Try

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Yoga can help relieve anxiety and stress through stimulating the nervous system. Learn about how it works, and poses to try, here.

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Why screen universally for trauma in behavioral health services? Exposure to trauma is common; in many surveys, more than half of respondents report a history of trauma, and the rates are even higher among clients with mental or substance use disorders. Furthermore, behavioral health problems, including substance use and mental disorders, are more difficult to treat if trauma-related symptoms and disorders aren't detected early and treated effectively ( Part 3, Section 1, of this Treatment Improvement Protocol [TIP], available online, summarizes research on the prevalence of trauma and its relationship with other behavioral health problems).

Not addressing traumatic stress symptoms, trauma-specific disorders, and other symptoms/disorders related to trauma can impede successful mental health and substance abuse treatment. Unrecognized, unaddressed trauma symptoms can lead to poor engagement in treatment, premature termination, greater risk for relapse of psychological symptoms or substance use, and worse outcomes. Screening can also prevent misdiagnosis and inappropriate treatment planning. People with histories of trauma often display symptoms that meet criteria for other disorders.

Without screening, clients' trauma histories and related symptoms often go undetected, leading providers to direct services toward symptoms and disorders that may only partially explain client screening for trauma history and trauma-related symptoms can help behavioral health practitioners identify individuals at risk of developing more pervasive and severe symptoms of traumatic stress. Screening, early identification, and intervention serves as a prevention strategy.

Screening to identify clients who have histories of trauma and experience trauma-related symptoms is a prevention strategy.

Trauma-Informed Care Framework in Behavioral Health Services-Screening and Assessment

The chapter begins with a discussion of screening and assessment concepts, with a particular focus on trauma-informed screening. It then highlights specific factors that influence screening and assessment, including timing and environment. Barriers and challenges in providing trauma-informed screening are discussed, along with culturally specific screening and assessment considerations and guidelines. Instrument selection, trauma-informed screening and assessment tools, and trauma-informed screening and assessment processes are reviewed as well. For a more research-oriented perspective on screening and assessment for traumatic stress disorders, please refer to the literature review provided in Part 3 of this TIP, which is available online.

Screening and Assessment

Screening

The first two steps in screening are to determine whether the person has a history of trauma and whether he or she has trauma-related symptoms. Screening mainly obtains answers to "yes" or "no" questions: "Has this client experienced a trauma in the past?" and "Does this client at this time warrant further assessment regarding trauma-related symptoms?" If someone acknowledges a trauma history, then further screening is necessary to determine whether trauma-related symptoms are present. However, the presence of such symptoms does not necessarily say anything about their severity, nor does a positive screen indicate that a disorder actually exists. Positive screens only indicate that assessment or further evaluation is warranted, and negative screens do not necessarily mean that an individual doesn't have symptoms that warrant intervention.

Screening is often the first contact between the client and the treatment provider, and the client forms his or her first impression of treatment during this intake process. Thus, how screening is conducted can be as important as the actual information gathered, as it sets the tone of treatment and begins the relationship with the client.

Screening procedures should always define the steps to take after a positive or negative screening. That is, the screening process establishes precisely how to score responses to screening tools or questions and clearly defines what constitutes a positive score (called a "cut-off score") for a particular potential problem. The screening procedures detail the actions to take after a client scores in the positive range. Clinical supervision is helpful-and sometimes necessary-in judging how to proceed.

Trauma-informed screening is an essential part of the intake evaluation and the treatment planning process, but it is not an end in itself. Screening processes can be developed that allow staff without advanced degrees or graduate-level training to conduct them, whereas assessments for trauma-related disorders require a mental health professional trained in assessment and evaluation processes. The most important domains to screen among individuals with trauma histories include:

Depressive or dissociative symptoms, sleep disturbances, and intrusive experiences.

Past and present mental disorders, including typically trauma-related disorders (e.g., mood disorders).

Severity or characteristics of a specific trauma type (e.g., forms of interpersonal violence, adverse childhood events, combat experiences).

Social support and coping styles.

Availability of resources.

Risks for self-harm, suicide, and violence.

Assessment

When a client screens positive for substance abuse, trauma-related symptoms, or mental disorders, the agency or counselor should follow up with an assessment. A positive screening calls for more action-an assessment that determines and defines presenting struggles to develop an appropriate treatment plan and to make an informed and collaborative decision about treatment placement. Assessment determines the nature and extent of the client's problems; it might require the client to respond to written questions, or it could involve a clinical interview by a mental health or substance abuse professional qualified to assess the client and arrive at a diagnosis. A clinical assessment delves into a client's past and cu r-rent experiences, psychosocial and cultural history, and assets and resources.

Assessment protocols can require more than a single session to complete and should also use multiple avenues to obtain the necessary clinical information, including self-assessment tools, past and present clinical and medical records, structured clinical interviews, assessment measures, and collateral information from significant others, other behavioral health professionals, and agencies. Qualifications for conducting assessments and clinical interviews are more rigorous than for screening. Advanced degrees, licensing or certification, and special training in administration, scoring, and interpretation of specific assessment instruments and interviews are often required. Counselors must be familiar with (and obtain) the level of training required for any instruments they consider using.

Advice to Counselors: Screening and Assessing Clients

Ask all clients about any possible history of trauma; use a checklist to increase proper identification of such a history (see the online Adverse Childhood Experiences Study Score Calculator [ http://acestudy.org/ace_score] for specific questions about adverse childhood experiences).

Use only validated instruments for screening and assessment.

Early in treatment, screen all clients who have histories of exposure to traumatic events for psychological symptoms and mental disorders related to trauma.

Do not delay screening; do not wait for a period of abstinence or stabilization of symptoms.

Be aware that some clients will not make the connection between trauma in their histories and their current patterns of behavior (e.g., alcohol and drug use and/or avoidant behavior).

Do not require clients to describe emotionally overwhelming traumatic events in detail.

Focus assessment on how trauma symptoms affect clients' current functioning.

Consider using paper-and-pencil instruments for screening and assessment as well as self-report measures when appropriate; they are less threatening for some clients than a clinical interview.

Talk about how you will use the findings to plan the client's treatment, and discuss any immediate action necessary, such as arranging for interpersonal support, referrals to community agencies, or moving directly into the active phase of treatment. It is helpful to explore the strategies clients have used in the past that have worked to relieve strong emotions ( Fallot & Harris, 2001).

At the end of the session, make sure the client is grounded and safe before leaving the interview room ( Litz, Miller, Ruef, & McTeague, 2002). Readiness to leave can be assessed by checking on the degree to which the client is conscious of the current environment, what the client's plan is for maintaining personal safety, and what the client's plans are for the rest of the day.

For people with histories of traumatic life events who screen positive for possible trauma-related symptoms and disorders, thorough assessment gathers all relevant information necessary to understand the role of the trauma in their lives; appropriate treatment objectives, goals, planning, and placement; and any ongoing diagnostic and treatment considerations, including reevaluation or follow-up.

Overall, assessment may indicate symptoms that meet diagnostic criteria for a substance use or mental disorder or a milder form of symptomatology that doesn't reach a diagnostic level-or it may reveal that the positive screen was false and that there is no significant cause for concern. Information from an assessment is used to plan the client's treatment.

The plan can include such domains as level of care, acute safety needs, diagnosis, disability, strengths and skills, support network, and cultural context. Assessments should reoccur throughout treatment. Ongoing assessment during treatment can provide valuable information by revealing further details of trauma history as clients' trust in staff members grows and by gauging clients' progress.

Timing of Screening and Assessment

As a trauma-informed counselor, you need to offer psychoeducation and support from the outset of service provision; this begins with explaining screening and assessment and with proper pacing of the initial intake and evaluation process. The client should understand the screening process, why the specific questions are important, and that he or she may choose to delay a response or to not answer a question at all. Discussing the occurrence or consequences of traumatic events can feel as unsafe and dangerous to the client as if the event were reoccurring. It is important not to encourage avoidance of the topic or reinforce the belief that discussing trauma-related material is dangerous, but be sensitive when gathering information in the initial screening. Initial questions about trauma should be general and gradual. Taking the time to prepare and explain the screening and assessment process to the client gives him or her a greater sense of control and safety over the assessment process.

Clients with substance use disorders

No screening or assessment of trauma should occur when the client is under the influence of alcohol or drugs. Clients under the influence are more likely to give inaccurate information. Although it's likely that clients in an active phase of use (albeit not at the assessment itself ) or undergoing substance withdrawal can provide consistent information to obtain a valid screening and assessment, there is insufficient data to know for sure. Some theorists state that no final assessment of trauma or posttraumatic stress disorder (PTSD) should occur during these early phases ( Read, Bollinger, & Sharkansky, 2003), asserting that symptoms of withdrawal can mimic PTSD and thus result in overdiagnosis of PTSD and other trauma-related disorders. Alcohol or drugs can also cause memory impairment that clouds the client's history of trauma symptoms. However, Najavits (2004) and others note that underdiagnosis, not overdiagnosis, of trauma and PTSD has been a significant issue in the substance abuse field and thus claim that it is essential to obtain an initial assessment early, which can later be modified if needed (e.g., if the client's symptom pattern changes). Indeed, clinical observations suggest that assessments for both trauma and PTSD- even during active use or withdrawal-appear robust ( Coffey, Schumacher, Brady, & Dansky, 2003). Although some PTSD symptoms and trauma memories can be dampened or increased to a degree, their overall presence or absence, as assessed early in treatment, appears accurate ( Najavits, 2004).

Conduct Assessments Throughout Treatment

Ongoing assessments let counselors:

Track changes in the presence, frequency, and intensity of symptoms.

Learn the relationships among the client's trauma, presenting psychological symptoms, and substance abuse.

Adjust diagnoses and treatment plans as needed.

Select prevention strategies to avoid more pervasive traumatic stress symptoms.

The Setting for Trauma Screening and Assessment

Advances in the development of simple, brief, and public-domain screening tools mean that at least a basic screening for trauma can be done in almost any setting. Not only can clients be screened and assessed in behavioral health treatment settings; they can also be evaluated in the criminal justice system, educational settings, occupational settings, physicians' offices, hospital medical and trauma units, and emergency rooms. Wherever they occur, trauma-related screenings and subsequent assessments can reduce or eliminate wasted resources, relapses, and, ultimately, treatment failures among clients who have histories of trauma, mental illness, and/or substance use disorders.

Creating an effective screening and assessment environment

You can greatly enhance the success of treatment by paying careful attention to how you approach the screening and assessment process. Take into account the following points:

Clarify for the client what to expect in the screening and assessment process. For example, tell the client that the screening and assessment phase focuses on identifying issues that might benefit from treatment. Inform him or her that during the trauma screening and assessment process, uncomfortable thoughts and feelings can arise. Provide reassurance that, if they do, you'll assist in dealing with this distress-but also let them know that, even with your assistance, some psychological and physical reactions to the interview may last for a few hours or perhaps as long as a few days after the interview, and be sure to highlight the fact that such reactions are normal ( Read et al., 2003).

Elicit only the information necessary for determining a history of trauma and the possible existence and extent of traumatic stress symptoms and related disorders. There is no need to probe deeply into the details of a client's traumatic experiences at this stage in the treatment process. Given the lack of a therapeutic relationship in which to process the information safely, pursuing details of trauma can cause retraumatization or produce a level of response that neither you nor your client is prepared to handle. Even if a client wants to tell his or her trauma story, it's your job to serve as "gatekeeper" and preserve the client's safety. Your tone of voice when suggesting postponement of a discussion of trauma is very important. Avoid conveying the message, "I really don't want to hear about it." Examples of appropriate statements are:

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"Your life experiences are very important, but at this early point in our work together, we should start with what's going on in your life currently rather than discussing past experiences in detail. If you feel that certain past experiences are having a big effect on your life now, it would be helpful for us to discuss them as long as we focus on your safety and recovery right now."

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"Talking about your past at this point could arouse intense feelings-even more than you might be aware of right now. Later, if you choose to, you can talk with your counselor about how to work on exploring your past."

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"Often, people who have a history of trauma want to move quickly into the details of the trauma to gain relief. I understand this desire, but my concern for you at this moment is to help you establish a sense of safety and support before moving into the traumatic experiences. We want to avoid retraumatization-meaning, we want to establish resources that weren't available to you at the time of the trauma before delving into more content."

Give the client as much personal control as possible during the assessment by:

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Presenting a rationale for the interview and its stress-inducing potential, making clear that the client has the right to refuse to answer any and all questions.

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Giving the client (where staffing permits) the option of being interviewed by someone of the gender with which he or she is most comfortable.

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Postponing the interview if necessary ( Fallot & Harris, 2001).

Use self-administered, written checklists rather than interviews when possible to assess trauma. Traumas can evoke shame, guilt, anger, or other intense feelings that can make it difficult for the client to report them aloud to an interviewer. Clients are more likely to report trauma when they use self-administered screening tools; however, these types of screening instruments only guide the next step. Interviews should coincide with self-administered tools to create a sense of safety for the client (someone is present as he or she completes the screening) and to follow up with more indepth data gathering after a self-administered screening is complete. The Trauma History Questionnaire (THQ) is a self-administered tool ( Green, 1996). It has been used successfully with clinical and nonclinical populations, including medical patients, women who have experienced domestic violence, and people with serious mental illness ( Hooper, Stockton, Krupnick, & Green, 2011). Screening instruments (including the THQ) are included in Appendix D of this TIP.

Barriers and Challenges to Trauma-Informed Screening and Assessment

Barriers

It is not necessarily easy or obvious to identify an individual who has survived trauma without screening. Moreover, some clients may deny that they have encountered trauma and its effects even after being screened or asked direct questions aimed at identifying the occurrence of traumatic events. The two main barriers to the evaluation of trauma and its related disorders in behavioral health settings are clients not reporting trauma and providers overlooking trauma and its effects.

Concerning the first main barrier, some events will be experienced as traumatic by one person but considered nontraumatic by another. A history of trauma encompasses not only the experience of a potentially traumatic event, but also the person's responses to it and the meanings he or she attaches to the event. Certain situations make it more likely that the client will not be forthcoming about traumatic events or his or her responses to those events. Some clients might not have ever thought of a particular event or their response to it as traumatic and thus might not report or even recall the event. Some clients might feel a reluctance to discuss something that they sense might bring up uncomfortable feelings (especially with a counselor whom they've only recently met). Clients may avoid openly discussing traumatic events or have difficulty recognizing or articulating their experience of trauma for other reasons, such as feelings of shame, guilt, or fear of retribution by others associated with the event (e.g., in cases of interpersonal or domestic violence). Still others may deny their history because they are tired of being interviewed or asked to fill out forms and may believe it doesn't matter anyway.

Common Reasons Why Some Providers Avoid Screening Clients for Trauma

Treatment providers may avoid screening for traumatic events and trauma-related symptoms due to:

A reluctance to inquire about traumatic events and symptoms because these questions are not a part of the counselor's or program's standard intake procedures.

Underestimation of the impact of trauma on clients' physical and mental health.

A belief that treatment of substance abuse issues needs to occur first and exclusively, before treating other behavioral health disorders.

A belief that treatment should focus solely on presenting symptoms rather than exploring the potential origins or aggravators of symptoms.

Not knowing how to respond therapeutically to a client's report of trauma.

Fear that a probing trauma inquiry will be too disturbing to clients.

Not using common language with clients that will elicit a report of trauma (e.g., asking clients if they were abused as a child without describing what is meant by abuse).

Concern that if disorders are identified, clients will require treatment that the counselor or program does not feel capable of providing ( Fallot & Harris, 2001).

Insufficient time for assessment to explore trauma histories or symptoms.

Untreated trauma-related symptoms of the counselor, other staff members, and administrators.

A client may not report past trauma for many reasons, including:

Concern for safety (e.g., fearing more abuse by a perpetrator for revealing the trauma).

Fear of being judged by service providers.

Shame about victimization.

Reticence about talking with others in response to trauma.

Not recalling past trauma through dissociation, denial, or repression (although genuine blockage of all trauma memory is rare among trauma survivors; McNally, 2003).

Lack of trust in others, including behavioral health service providers.

Not seeing a significant event as traumatic.

Regarding the second major barrier, counselors and other behavioral health service providers may lack awareness that trauma can significantly affect clients' presentations in treatment and functioning across major life areas, such as relationships and work. In addition, some counselors may believe that their role is to treat only the presenting psychological and/or substance abuse symptoms, and thus they may not be as sensitive to histories and effects of trauma. Other providers may believe that a client should abstain from alcohol and drugs for an extended period before exploring trauma symptoms. Perhaps you fear that addressing a clients' trauma history will only exacerbate symptoms and complicate treatment. Behavioral health service providers who hold biases may assume that a client doesn't have a history of trauma and thus fail to ask the "right" questions, or they may be uncomfortable with emotions that arise from listening to client experiences and, as a result, redirect the screening or counseling focus.

Challenges

Awareness of acculturation and language

Acculturation levels can affect screening and assessment results. Therefore, indepth discussions may be a more appropriate way to gain an understanding of trauma from the client's point of view. During the intake, prior to trauma screening, determine the client's history of migration, if applicable, and primary language. Questions about the client's country of birth, length of time in this country, events or reasons for migration, and ethnic self-identification are also appropriate at intake. Also be aware that even individuals who speak English well might have trouble understanding the subtleties of questions on standard screening and assessment tools. It is not adequate to translate items simply from English into another language; words, idioms, and examples often don't translate directly into other languages and therefore need to be adapted. Screening and assessment should be conducted in the client's preferred language by trained staff members who speak the language or by professional translators familiar with treatment jargon.

Common Assessment Myths

Several common myths contribute to underassessment of trauma-related disorders ( Najavits, 2004):

Myth #1: Substance abuse itself is a trauma. However devastating substance abuse is, it does not meet the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013a), criteria for trauma per se. Nevertheless, high-risk behaviors that are more likely to occur during addiction, such as interpersonal violence and self-harm, significantly increase the potential for traumatic injury.

Myth #2: Assessment of trauma is enough. Thorough assessment is the best way to identify the existence and extent of trauma-related problems. However, simply identifying trauma-related symptoms and disorders is just the first step. Also needed are individualized treatment protocols and action to implement these protocols.

Myth #3: It is best to wait until the client has ended substance use and withdrawal to assess for PTSD. Research does not provide a clear answer to the controversial question of when to assess for PTSD; however, Najavits (2004) and others note that underdiagnosis of trauma and PTSD has been more significant in the substance abuse field than overdiagnosis. Clinical experience shows that the PTSD diagnosis is rather stable during substance use or withdrawal, but symptoms can become more or less intense; memory impairment from alcohol or drugs can also cloud the symptom picture. Thus, it is advisable to establish a tentative diagnosis and then reassess after a period of abstinence, if possible.

Awareness of co-occurring diagnoses

A trauma-informed assessor looks for psychological symptoms that are associated with trauma or simply occur alongside it. Symptom screening involves questions about past or present mental disorder symptoms that may indicate the need for a full mental health assessment. A variety of screening tools are available, including symptom checklists.

However, you should only use symptom checklists when you need information about how your client is currently feeling; don't use them to screen for specific disorders. Responses will likely change from one administration of the checklist to the next.

Basic mental health screening tools are available. For example, the Mental Health Screening Form-III screens for present or past symptoms of most mental disorders ( Carroll & McGinley, 2001); it is available at no charge from Project Return Foundation, Inc. and is also reproduced in TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders ( CSAT, 2005c). Other screening tools, such as the Beck Depression Inventory II and the Beck Anxiety Inventory ( Beck, Wright, Newman, & Liese, 1993), also screen broadly for mental and substance use disorders, as well as for specific disorders often associated with trauma. For further screening information and resources on depression and suicide, see TIP 48, Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery ( CSAT, 2008), and TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment ( CSAT, 2009a).

For screening substance use disorders, see TIP 11, Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases ( CSAT, 1994); TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians ( CSAT, 1997a); TIP 31, Screening and Assessing Adolescents for Substance Use Disorders ( CSAT, 1999c); TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders ( CSAT, 2005c); and TIP 51, Substance Abuse Treatment: Addressing the Specific Needs of Women ( CSAT, 2009d).

A common dilemma in the assessment of trauma-related disorders is that certain trauma symptoms are also symptoms of other disorders. Clients with histories of trauma typically present a variety of symptoms; thus, it is important to determine the full scope of symptoms and/or disorders present to help improve treatment planning. Clients with trauma-related and substance use symptoms and disorders are at increased risk for additional Axis I and/or Axis II mental disorders ( Brady, Killeen, Saladin, Dansky, & Becker, 1994; Cottler, Nishith, & Compton, 2001). These symptoms need to be distinguished so that other presenting subclinical features or disorders do not go unidentified and untreated. To accomplish this, a comprehensive assessment of the client's mental health is recommended.

Misdiagnosis and underdiagnosis

Many trauma survivors are either misdiagnosed (i.e., given diagnoses that are not accurate) or underdiagnosed (i.e., have one or more diagnoses that have not been identified at all). Such diagnostic errors could result, in part, from the fact that many general instruments to evaluate mental disorders are not sufficiently sensitive to identify posttraumatic symptoms and can misclassify them as other disorders, including personality disorders or psychoses. Intrusive posttraumatic symptoms, for example, can show up on general measures as indicative of hallucinations or obsessions. Dissociative symptoms can be interpreted as indicative of schizophrenia. Trauma-based cognitive symptoms can be scored as evidence for paranoia or other delusional processes ( Briere, 1997). Some of the most common misdiagnoses in clients with PTSD and substance abuse are:

It is possible, however, for clients to legitimately have any of these disorders in addition to trauma-related disorders. Given the overlap of posttraumatic symptoms with those of other disorders, a wide variety of diagnoses often needs to be considered to avoid misidentifying other disorders as PTSD and vice versa. A trained and experienced mental health professional will be required to weigh differential diagnoses. TIP 42 ( CSAT, 2005c) explores issues related to differential diagnosis.

Cross-Cultural Screening and Assessment

Many trauma-related symptoms and disorders are culture specific, and a client's cultural background must be considered in screening and assessment (for review of assessment and cultural considerations when working with trauma, see Wilson & Tang, 2007). Behavioral health service providers must approach screening and assessment processes with the influences of culture, ethnicity, and race firmly in mind. Cultural factors, such as norms for expressing psychological distress, defining trauma, and seeking help in dealing with trauma, can affect:

How traumas are experienced.

The meaning assigned to the event(s).

How trauma-related symptoms are expressed (e.g., as somatic expressions of distress, level of emotionality, types of avoidant behavior).

Willingness to express distress or identify trauma with a behavioral health service provider and sense of safety in doing so.

Whether a specific pattern of behavior, emotional expression, or cognitive process is considered abnormal.

Willingness to seek treatment inside and outside of one's own culture.

When selecting assessment instruments, counselors and administrators need to choose, whenever possible, instruments that are culturally appropriate for the client. Instruments that have been normed for, adapted to, and tested on specific cultural and linguistic groups should be used. Instruments that are not normed for the population are likely to contain cultural biases and produce misleading results. Subsequently, this can lead to misdiagnosis, overdiagnosis, inappropriate treatment plans, and ineffective interventions. Thus, it is important to interpret all test results cautiously and to discuss the limitations of instruments with clients from diverse ethnic populations and cultures. For a review of cross-cultural screening and assessment considerations, refer to the planned TIP, Improving Cultural Competence (Substance Abuse and Mental Health Services Administration, planned c).

Culture-Specific Stress Responses

Culture-bound concepts of distress exist that don't necessarily match diagnostic criteria. Culture-specific symptoms and syndromes can involve physical complaints, broad emotional reactions, or specific cognitive features. Many such syndromes are unique to a specific culture but can broaden to cultures that have similar beliefs or characteristics. Culture-bound syndromes are typically treated by traditional medicine and are known throughout the culture. Cultural concepts of distress include:

Ataques de nervios. Recognized in Latin America and among individuals of Latino descent, the primary features of this syndrome include intense emotional upset (e.g., shouting, crying, trembling, dissociative or seizure-like episodes). It frequently occurs in response to a traumatic or stressful event in the family.

Nervios. This is considered a common idiom of distress among Latinos; it includes a wide range of emotional distress symptoms including headaches, nervousness, tearfulness, stomach discomfort, difficulty sleeping, and dizziness. Symptoms can vary widely in intensity, as can impairment from them. This often occurs in response to stressful or difficult life events.

Susto. This term, meaning "fright," refers to a concept found in Latin American cultures, but it is not recognized among Latinos from the Caribbean. Susto is attributed to a traumatic or frightening event that causes the soul to leave the body, thus resulting in illness and unhappiness; extreme cases may result in death. Symptoms include appetite or sleep disturbances, sadness, lack of motivation, low self-esteem, and somatic symptoms.

Taijin kyofusho. Recognized in Japan and among some American Japanese, this "interpersonal fear" syndrome is characterized by anxiety about and avoidance of interpersonal circumstances. The individual presents worry or a conviction that his or her appearance or social interactions are inadequate or offensive. Other cultures have similar cultural descriptions or syndromes associated with social anxiety.

Sources: APA, 2013, pp. 833-837; Briere & Scott, 2006b.

Choosing Instruments

Numerous instruments screen for trauma history, indicate symptoms, assess trauma-related and other mental disorders, and identify related clinical phenomena, such as dissociation. One instrument is unlikely to meet all screening or assessment needs or to determine the existence and full extent of trauma symptoms and traumatic experiences. The following sections present general considerations in selecting standardized instruments.

Purpose

Define your assessment needs. Do you need a standardized screening or assessment instrument for clinical purposes? Do you need information on a specific aspect of trauma, such as history, PTSD, or dissociation? Do you wish to make a formal diagnosis, such as PTSD? Do you need to determine quickly whether a client has experienced a trauma? Do you want an assessment that requires a clinician to administer it, or can the client complete the instrument himself or herself? Does the instrument match the current and specific diagnostic criteria established in the DSM-5?

Population

Consider the population to be assessed (e.g., women, children, adolescents, refugees, disaster survivors, survivors of physical or sexual violence, survivors of combat-related trauma, people whose native language is not English); some tools are appropriate only for certain populations. Is the assessment process developmentally and culturally appropriate for your client? Exhibit 1.4-2 lists considerations in choosing a screening or assessment instrument for trauma and/or PTSD.

Instrument Quality

An instrument should be psychometrically adequate in terms of sensitivity and specificity or reliability and validity as measured in several ways under varying conditions. Published research offers information on an instrument's psychometric properties as well as its utility in both research and clinical settings. For further information on a number of widely used trauma evaluation tools, see Appendix D and Antony, Orsillo, and Roemer's paper (2001).

The DSM-5 and Updates to Screening and Assessment Instruments

The recent publication of the DSM-5 ( APA, 2013a) reflects changes to certain diagnostic criteria, which will affect screening tools and criteria for trauma-related disorders. Criterion A2 (specific to traumatic stress disorders, acute stress, and posttraumatic stress disorders), included in the fourth edition (text revision) of the DSM (DSM-IV-TR; APA, 2000a), has been eliminated; this criterion stated that the individual's response to the trauma needs to involve intense fear, helplessness, or horror. There are now four cluster symptoms, not three: reexperiencing, avoidance, arousal, and persistent negative alterations in cognitions and mood. Changes to the DSM-5 were made to symptoms within each cluster. Thus, screening will need modification to adjust to this change ( APA, 2012b).

Practical Issues

Is the instrument freely and readily available, or is there a fee? Is costly and extensive training required to administer it? Is the instrument too lengthy to be used in the clinical setting? Is it easily administered and scored with accompanying manuals and/or other training materials? How will results be presented to or used with the client? Is technical support available for difficulties in administration, scoring, or interpretation of results? Is special equipment required such as a microphone, a video camera, or a touch-screen computer with audio?

Trauma-Informed Screening and Assessment

The following sections focus on initial screening. For more information on screening and assessment tools, including structured interviews, see Exhibit 1.4-2. Screening is only as good as the actions taken afterward to address a positive screen (when clients acknowledge that they experience symptoms or have encountered events highlighted within the screening). Once a screening is complete and a positive screen is acquired, the client then needs referral for a more indepth assessment to ensure development of an appropriate treatment plan that matches his or her presenting problems.

Establish a History of Trauma

A person cannot have ASD, PTSD, or any trauma-related symptoms without experiencing trauma; therefore, it is necessary to inquire about painful, difficult, or overwhelming past experiences. Initial information should be gathered in a way that is minimally intrusive yet clear. Brief questionnaires can be less threatening to a client than face-to-face interviews, but interviews should be an integral part of any screening and assessment process.

If the client initially denies a history of trauma (or minimizes it), administer the questionnaire later or delay additional trauma-related questions until the client has perhaps developed more trust in the treatment setting and feels safer with the thoughts and emotions that might arise in discussing his or her trauma experiences.

The Stressful Life Experiences (SLE) screen ( Exhibit 1.4-3) is a checklist of traumas that also considers the client's view of the impact of those events on life functioning. Using the SLE can foster the client-counselor relationship. By going over the answers with the client, you can gain a deep understanding of your client, and the client receives a demonstration of your sensitivity and concern for what the client has experienced. The National Center for PTSD Web site offers similar instruments ( http://www.ptsd.va.gov/professional/pages/assessments/assessment.asp).

In addition to broad screening tools that capture various traumatic experiences and symptoms, other screening tools, such as the Combat Exposure Scale ( Keane et al., 1989) and the Intimate Partner Violence Screening Tool ( Exhibit 1.4-4), focus on acknowledging a specific type of traumatic event.

Screen for Trauma-Related Symptoms and Disorders in Clients With Histories of Trauma

This step evaluates whether the client's trauma resulted in subclinical or diagnosable disorders. The counselor can ask such questions as, "Have you received any counseling or therapy? Have you ever been diagnosed or treated for a psychological disorder in the past? Have you ever been prescribed medications for your emotions in the past?" Screening is typically conducted by a wide variety of behavioral health service providers with different levels of training and education; however, all individuals who administer screenings, regardless of education level and experience, should be aware of trauma-related symptoms, grounding techniques, ways of creating safety for the client, proper methods for introducing screening tools, and the protocol to follow when a positive screen is obtained. (See Appendix D for information on specific instruments.) Exhibit 1.4-5 is an example of a screening instrument for trauma symptoms, the Primary Care PTSD (PC-PTSD) Screen. Current research ( Prins et al., 2004) suggests that the optimal cutoff score for the PC-PTSD is 3. If sensitivity is of greater concern than efficiency, a cutoff score of 2 is recommended.

Another instrument that can screen for traumatic stress symptoms is the four-item self-report SPAN, summarized in Exhibit 1.4-6, which is derived from the 17-item Davidson Trauma Scale (DTS). SPAN is an acronym for the four items the screening addresses: startle, physiological arousal, anger, and numbness. It was developed using a small, diverse sample of adult patients (N=243; 72 percent women; 17.4 percent African American; average age = 37 years) participating in several clinical studies, including a family study of rape trauma, combat veterans, and Hurricane Andrew survivors, among others.

The SPAN has a high diagnostic accuracy of 0.80 to 0.88, with sensitivity (percentage of true positive instances) of 0.84 and specificity (percentage of true negative instances) of 0.91 ( Meltzer-Brody, Churchill, & Davidson, 1999). SPAN scores correlated highly with the full DTS (r = 0.96) and other measures, such as the Impact of Events Scale (r = 0.85) and the Sheehan Disability Scale (r = 0.87).

The PTSD Checklist ( Exhibit 1.4-7), developed by the National Center for PTSD, is in the public domain. Originally developed for combat veterans of the Vietnam and Persian Gulf Wars, it has since been validated on a variety of noncombat traumas ( Keane, Brief, Pratt, & Miller, 2007). When using the checklist, identify a specific trauma first and then have the client answer questions in relation to that one specific trauma.

Other Screening and Resilience Measures

Along with identifying the presence of trauma-related symptoms that warrant assessment to determine the severity of symptoms as well as whether or not the individual possesses subclinical symptoms or has met criteria for a trauma-related disorder, clients should receive other screenings for symptoms associated with trauma (e.g., depression, suicidality). It is important that screenings address both external and internal resources (e.g., support systems, strengths, coping styles). Knowing the client's strengths can significantly shape the treatment planning process by allowing you to use strategies that have already worked for the client and incorporating strategies to build resilience ( Exhibit 1.4-8).

Preliminary research shows improvement of individual resilience through treatment interventions in other populations ( Lavretsky, Siddarth, & Irwin, 2010).

Screen for suicidality

All clients-particularly those who have experienced trauma-should be screened for suicidality by asking, "In the past, have you ever had suicidal thoughts, had intention to commit suicide, or made a suicide attempt? Do you have any of those feelings now? Have you had any such feelings recently?" Behavioral health service providers should receive training to screen for suicide. Additionally, clients with substance use disorders and a history of psychological trauma are at heightened risk for suicidal thoughts and behaviors; thus, screening for suicidality is indicated. See TIP 50, Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment ( CSAT, 2009a). For additional descriptions of screening processes for suicidality, see TIP 42 ( CSAT, 2005c).

Concluding Note

Screenings are only beneficial if there are follow-up procedures and resources for handling positive screens, such as the ability to review results with and provide feedback to the individual after the screening, sufficient resources to complete a thorough assessment or to make an appropriate referral for an assessment, treatment planning processes that can easily incorporate additional trauma-informed care objectives and goals, and availability and access to trauma-specific services that match the client's needs. Screening is only the first step!

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Why screen universally for trauma in behavioral health services? Exposure to trauma is common; in many surveys, more than half of respondents report a history of trauma, and the rates are even higher among clients with mental or substance use disorders.

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How do drugs and alcohol affect mental health?

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This section explains how using drugs and alcohol can affect your mental health. It also explains how you can get help to stop using drugs and alcohol. In this section, 'drugs' means recreational drugs, alcohol, or prescription drugs. When someone with a mental illness also uses drugs, doctors call this 'dual diagnosis' or 'co-occurring diagnosis'.

If you would like more advice or information you can contact our Advice and Information Service by clicking .

Overview

There are many reasons why you might use drugs and alcohol.

Some people use them to try and deal with their symptoms of their mental illness. This is called 'self-medication'.

Drugs and alcohol can make the symptoms of your mental illness worse.

Some drugs may make it more likely for you to get a mental illness, and they may make it harder to treat.

Mental health, and drug and alcohol services should work together to give you the support you need.

If you have any problems getting help, you could make a complaint.

Need more advice?

If you need more advice or information you can contact our Advice and Information Service.

About

How can drugs and alcohol affect my mental health?

People use drugs and drink alcohol for lots of different reasons. Whatever your reason, using drugs or alcohol may have a long-term negative effect on you. The possible long-term effects include the following.

Needing to take more to get the same effect.

High blood pressure and strokes.

Problems with your liver and pancreas.

Development of certain cancers e.g. liver cancer, bowel cancer and mouth cancer.

Difficulty obtaining or maintaining an erection.

Problems with orgasms.

Difficulties becoming pregnant.

Feeling like you must use the drug or alcohol. This is known as being dependent.

Withdrawal symptoms including feeling sick, cold, sweaty or shaky when you don't take them.

Having sudden mood changes.

Having a negative outlook on life.

Loss of motivation.

Depression.

Anxiety.

Problems with relationships.

Being secretive.

Having episodes of drug-induced psychosis.

If you use alcohol or drugs for a long time it can cause serious issues for your mental well-being. Drugs can make you more unwell and more likely to try and harm yourself or take your own life.

There is also some evidence that using some drugs may cause mental illness for the first time. For example, research has shown that cannabis can increase your chances of developing psychosis or a psychotic disorder.

You can find more information about 'Cannabis and mental health' by clicking here.

What is psychosis?

Psychosis is a medical term. If you have psychosis you will process the world around you differently to other people. This can include how you experience, believe or view things.

You might see or hear things that others do not. Or believe things other people do not. Some people describe it as a "break from reality". There are different terms use to describe psychosis. Such as "psychotic symptoms", "psychotic episode" or "psychotic experience."

It can be a symptom of mental illness and can also be a short-term effect of some drugs.

You can find more information about 'Psychosis' by clicking here.

Drugs and effects

Which substances can affect my mental health?

In this section we have listed some of the different types of substances that could have an impact on your mental health. Please be aware that this list is not a list of all substances.

Taking any substances can be dangerous. They can also have bad interactions with any medications or other substances you might use.

For more information on different substances you can visit the website of 'Talk to Frank'. They are a specialist charity that provides information on drugs. You can find their website here: www.talktofrank.com/

Cannabis

(Also known as: bud, bhang, dope, draw, ganja, grass, hash, herb, marijuana, pot, skunk, weed)

Cannabis is one of the most commonly used drugs in England. According to one study, 1 in 13 people aged 16-59 had used it in the last year. Young people aged 16-24 are more likely to use cannabis. The same study shows that just under 1 in 5 young people had used cannabis between 2018 and 2019.

Some people take cannabis because it makes them feel relaxed or happy, but It can also make you feel anxious or feel paranoid. Some people may experience things that aren't real. This is a sign of drug-induced psychosis. Some studies have shown that the risk of psychosis may be higher if you:

use cannabis for a long time,

use it frequently, and

use 'high-strength' cannabis, like skunk.

If you have been using cannabis and you feel that it is affecting your health, make an appointment to see your GP as soon as you can. Your doctor should not judge you and should not tell other people you use drugs.

Alcohol

(Also known as: bevvies, booze)

Some people with a mental illness have problems using alcohol. Alcohol is legal, which means it is easier to get. It can make the feelings of some mental health issues feel worse.

The long-term effects of alcohol also depend on how much you drink, and how regularly you drink it. If you drink too much on a regular basis then you could cause yourself serious physical and mental harm.

Drinking can make you do something you would not normally do. This can include self-harm and suicide. Very high levels of alcohol can cause psychosis.

New Psychoactive Substances (NPS)

(Also known as: PlantFood, NPS, Mdat, Eric 3, Dimethocaine and Bath salts).

These are drugs that contain one or more chemical substance. They produce effects that are similar to cocaine, cannabis and ecstasy.

Some of the drugs classed as NPS used to be known as 'legal highs'. This is a common term that people use. It is used because some NPS were legal before 2016. However, the name is now wrong, because since 2016 they have been made illegal.

The short-term effects of an NPS depend on what you take.

Some new psychoactive drugs can cause confusion and a feeling of panic. You can also have hallucinations. This is when you see, smell, hear or feel things that other people don't. Hallucinations can affect the way you behave. Your behaviour can become erratic and can put your own safety at serious risk.

These drugs can also affect your judgement, which could put you at risk.

Some NPS can be very dangerous. They can kill you or hurt you very badly. There is a higher risk of this if taken with alcohol or other psychoactive drugs.

Amphetamine and methamphetamine

(Also known as: Crystal Meth, Ice, Meth, Glass, Whizz, Speed, Billy, Base, Yaba, Tina and Christine)

In the short-term, these drugs can make you feel wide awake and alert. This can make it difficult for you to relax or get to sleep. They might cause you to have a drug-induced psychosis. In the long-term, amphetamines might make you anxious and depressed. They can also be addictive.

When you stop taking the drug, you may feel depressed and you might find it hard to sleep.

Benzodiazepines

(Also known as: Benzos, Blues, Downers, Roofies, Vallies, Diazepam, Rohypnol, Valium, Xanax)

Benzodiazepines are a type of tranquilisers. They are used to treat anxiety. They are also used as a muscle relaxant. Sometimes a doctor will tell you to take benzodiazepines to help you with anxiety. But people also buy them illegally because of their relaxing effects. They can be addictive, and so doctors only give them for a short time.

In the short-term, these drugs can make you feel calmer. Depending on the type you take, they could make you feel confused or overly sleepy.

Taking benzodiazepines with other drugs or alcohol can be dangerous. It can affect your breathing. It can also increase the risk of overdose and death.

In the long-term, some people become addicted. This can have a big effect on their day-to-day life.

You can find more information on 'Benzodiazepines' by clicking here.

Cocaine

(Also known as: Blow, Crack, Coke, Charlie, Chang, Freebase, Sniff, Snow)

In the short-term, cocaine can make you feel awake, talkative and confident. After this wears off, you can feel tired and depressed after taking it.

In the long-term, cocaine use can affect how you feel. It can affect your relationships with friends and family. Cocaine is also addictive and over time you are more likely to have ongoing problems with depression, paranoia or anxiety.

Cocaine can cause fits, heart attacks and strokes. If you mix it with some other drugs you are more likely to overdose or die.

Ecstasy

(Also known as: E, MDMA, MD, Molly, Pills, XTC)

In the short-term, ecstasy may make you feel energetic, very happy, chatty and confident. It can also sometimes make you feel anxious, confused or trigger drug-induced psychosis.

In the long-term, ecstasy use can lead to memory problems. You may also develop depression and anxiety.

Heroin

(Also known as: Brown, Gear, H, Smack, Skag)

In the short-term, heroin can make you feel relaxed and happy. It takes away pain and can make you feel sleepy. But there is a higher risk that you could take too much or overdose with heroin than some other drugs.

Heroin can be taken in lots of different ways, including by injection. However, there is a high risk of getting an infection if you inject heroin, particularly if you share needles with someone else.

Heroin is very addictive. It can have serious long-term effects. You may feel that heroin becomes more important than other things in your life. This might make it harder to keep a job and affect your relationships.

LSD

(Also known as: Acid, Blotter, Trips, Micro-dot)

In the short-term, LSD may make you experience things that aren't real. Sometimes the experience will be enjoyable, and sometimes it will be frightening. This is known as a bad trip.

If you have a history of mental health problems taking LSD can make it worse. If you panic during a trip on LSD it can be scary. LSD may also trigger mental health problems which you haven't experienced before.

Getting help

How can I get help?

If you have a mental illness and use drugs, the NHS may call this 'dual diagnosis' or 'co-occurring diagnosis'. Your local NHS trust may have a policy that says how they will help people with dual diagnosis. Check on their website to see if you can find out more about what to expect locally.

If you are not already getting help with your mental health from your local mental health team, a good first step is to make an appointment to see your GP. Your GP may offer you medication and therapy to treat your mental illness. They may refer you to a drug and alcohol service to help you with your drug use.

If your needs are too complicated for your GP to deal with alone, you might need more specialist support. A GP can refer you to your local mental health service or community mental health team (CMHT).

They should offer this support and work with drug and alcohol services to give you all the help you need. The Department of Health and Social Care says that people with dual diagnosis are a key group of people who should get help from mental health services. You should not be stopped from getting help if you have drug or alcohol problems and severe mental illness.

Care Programme Approach (CPA)

The National Institute for Health and Care Excellence (NICE) produces guidance for the NHS and other organisations responsible for people's health and care. They say that people who have a severe mental illness and drug or alcohol problem should get help under the Care Programme Approach (CPA). The CPA is a framework that the NHS uses to plan someone's long-term care.

Under the CPA you will have a care co-ordinator to plan your care. They will help to write a care plan. This should account for all the different needs you might have such as:

NICE also say that you should be able to give your views on the care plan to make sure that it meets your needs. And the care plan should be shared with your carers or family if you agree.

You can read the NICE guidance online here:
www.nice.org.uk/guidance/ng58

There may be a team in your area which helps people with dual diagnosis. It is sometimes called the dual diagnosis team. However, not all areas of the country have them, and it may have a different name. If there isn't one in your area, you could try contacting your local community mental health team (CMHT) for help. However, you will need to be referred to the CMHT by your GP.

As well as NHS services, you could try contacting local charities. Many charities have support services or support groups for people struggling with substance misuse. You can find some national charities listed in the Useful Contacts section below.

You can find more information about:

NHS Mental Health Teams (MHTs) by clicking here.

Worried about your mental health? by clicking here.

Care Programme Approach by clicking here.

Problems

What can I do if I have problems trying to get help?

Some people with dual diagnosis have told us that it has been difficult to get the help they need. For example, you may have been told that mental health services cannot help you because of your drink or drugs problem.

But the Department of Health and Social Care is very clear that mental health services should try to help you if you have dual diagnosis.

The National Institute for Health and Care Excellence (NICE) also say that you should not be turned away from mental health services because you have a drug or alcohol problem.

If your mental health team have said they can't help you then you can ask them what their reasons are. You can ask for a copy of their policy for eligibility criteria. You may then be able to use this to show you are eligible for their support.

If you are not happy with the services you get, talk to the person in charge of your care. This might be your GP or your 'care coordinator'. They might be able to change things for you. An 'advocate' may be able to help you to get your point of view across. You might need to make a complaint to the NHS if you do not get the help you need.

You can find more information about:

Carer's, friends and relatives

What if I am a carer, friend or relative?

Supporting someone struggling with dual diagnosis can be difficult. It might help to speak to the person you are helping, to see what support they want. For example, some people might just want someone to talk with. Other people might want more practical help, such as with booking appointments or helping them speak to professionals.

We Are With You and Adfam are two charities that offer support and advice to relatives, friends and carers of those struggling with substance misuse. You can find their contact details in the Useful Contacts section below.

You might also feel that you need support for yourself. The National Institute for Health and Care Excellence (NICE) says that carers who support someone with a dual diagnosis should be offered a carer's assessment under the Care Act 2014. You may be able to get practical support to help you with your caring responsibilities.

NICE also says that if you are caring for someone with a dual diagnosis you can:

be involved in their care planning, and

work with services to help those services improve.

But this can only happen if the person who you care for wants you to be involved. Speak to the mental health team if you have ideas about what services should be available or how things could work better.

You can find more information about:

Useful contacts

Drinkline
This is the national alcohol helpline. They provide information and selfhelp materials for callers worried about their own drinking, and to support the family and friends of people who are drinking. They are confidential, you do not have to give your name and they can provide advice on where to get help.

Adfam
This is a national charity for families and friends of drug users. It offers confidential support and information.

Frank
Frank provides information and advice on drugs to anyone concerned about drugs and solvent misuse, including people misusing drugs, their families, friends and carers.

Telephone: 0300 123 6600. Open 24 hours a day, every day
Text: 82111
Email: Online form here: www.talktofrank.com/contact
Webchat: www.talktofrank.com/contact-frank Open 2pm-6pm every day.
Website: www.talktofrank.com

Alcohol Change UK
Alcohol concern is the national organisation for alcohol misuse. It does not provide services, but they do produce information on alcohol.

We Are With You
This is a drug and alcohol treatment agency. Their services deal primarily with drug and alcohol problems including support for families.

Al-Anon Family Groups
This is a service for families and friends of alcoholics. Al-Anon family groups provide understanding, strength and hope to anyone whose life is, or has been, affected by someone else's drinking.

Narcotics Anonymous UK (NAUK)
NA is a non-profit fellowship or society of men and women for whom drugs had become a major problem. They are recovering addicts who meet regularly to help each other stay clean. They have groups around the country.

Helpline: 0300 999 1212 10am - midnight
Website: www.ukna.org/

Alcoholics Anonymous (AA)
AA provides an opportunity for people to get together to solve their problem with alcohol and help others to recover.

Cocaine Anonymous (CA)
CA is a fellowship of men and women who use the 12 step, self-help programme to stop cocaine and all other mind-altering substances.

DrugWise
DrugWise provides information and publications on a wide range of drug related topics.

Website: www.drugwise.org.uk/

PostScript 360
A charity committed to supporting individuals to reduce the harms caused by prescribed drugs that are associated with dependence and withdrawal. They do this through a wrap-around service of one to one therapy, group therapy and a telephone support service.

Release
They offer advice and information on drug problems. They have expertise in legal matters surrounding drugs.

Turning Point
This is an organisation that works with people affected by drug and alcohol misuse, mental health problems and learning disabilities.

Address: Standon House, 21 Mansell Street, London, E1 8AA
Email:
Website: www.turning-point.co.uk

Need more advice?

If you need more advice or information you can contact our Advice and Information Service.

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How do drugs and alcohol affect mental health?

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People use drugs and drink alcohol for lots of different reasons. Whatever your reason, using drugs or alcohol may have a long-term negative effect on you. It may take longer for your mental health to get better if you use drugs or alcohol.

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Many people turn to yoga for stress and anxiety relief. Learn how yoga for anxiety works, plus some basic poses to get started.

Many people living with anxiety use a combination of methods to manage their symptoms, including therapy, lifestyle changes, and often, alternative treatments like yoga.

Anxiety disorders affect more than 40 million ( 18.1%) U.S. adults over age 18 each year. Anxiety is treatable, but only around 40% of people are receiving treatment.

Over the years, research studies have shown that yoga can help relieve stress and anxiety. It works by soothing an overactive nervous system, relaxing both the mind and body.

The 2021 State of Mental Health in America Report shows that the number of people seeking help for their anxiety disorders has skyrocketed during the COVID-19 pandemic, so right now, the need for effective anxiety management is especially high.

Yoga is an accessible, adaptable practice you can do from the comfort of your own home. The practice can be modified to accommodate bodies of all types, abilities, and backgrounds.

If you live with chronic anxiety, your nervous system - specifically your sympathetic nervous system, also known as the fight, flight, or freeze system - is operating in overdrive. This means your body has a heightened reaction to perceived threat, leading to anxiety responses such as agitation, stress, and heart palpitations.

As a consequence, you also have an underactive parasympathetic nervous system, or your rest-and-digest system. This system regulates your physiological functions, like heart rate and digestion.

According to research, stimulating the vagus nerve - a key part of the rest-and-digest system - is key to modulating the fight, flight, or freeze stress response.

One way to stimulate the vagus nerve is through practicing yoga.

Yoga poses stimulate the vagus nerve

"The parasympathetic nervous system helps us to feel safe and calm, and various aspects of yoga help to stimulate it," says Valerie Knopik, PhD, a psychologist, professor at Purdue University, and yoga instructor at Yoga Medicine based in Indianapolis, Indiana.

Yoga stimulates the vagus nerve by enhancing interoception, or how we perceive sensations arising in the body.

"Practices that increase interoception enable a person to distinguish between safe and fearful or dangerous situations," Knopik says.

Yoga also increases vagal tone, which means your body is able to relax sooner after stress. Knopik says that increasing your vagal tone could reduce the symptoms of nervous system dysfunction, such as feelings of anxiety.

Yoga offers many opportunities to experience interoception and stimulate the vagus nerve. Through physical movement, you can explore sensation as it arises in your body by developing awareness of what muscles are being challenged, stretched, or released.

Pranayama breath work connects the mind and body

Yoga, which means union, connects the mind and body through the breath. Pranayama, a Sanskrit term that describes how the breath is regulated during yoga, is a powerful tool for calming the sympathetic nervous system.

As Knopik explains, pranayama is a voluntary breathing practice that sends messages to the brain via the respiratory system.

"Certain breath practices can help with feelings of relaxation and calm, such as the long exhale or diaphragmatic breathing, primarily through stimulation of the vagus nerve and the vagus nerve's connection to heart rate variability," Knopik says.

But not all forms of pranayama may be appropriate for anxiety.

"Some breath practices are meant to be invigorating and more stimulating, such as Kapalabhati ('Breath of Fire'), which can stimulate the sympathetic nervous system and not the parasympathetic nervous system," she says.

Depending on the severity of your anxiety symptoms, pranayama that encourages deeper, steadier breathing patterns, such as Ujjayi breath, may be more suitable.

Meditation promotes relaxation

"Meditation is perhaps the most interoceptive practice of all and encourages us to watch our thoughts," Knopik says. "Practicing meditation can help with self-regulation and mindfulness, which helps to keep us in our bodies and out of our thoughts."

Yoga poses (asanas) are a vehicle for exploration of the present moment. Observing your thoughts that arise during mindful movement is a practice of building awareness. This can promote relaxation.

A 2012 research review suggests that meditative therapies (i.e., meditation, yoga, qigong, etc.) are effective tools for alleviating anxiety symptoms.

The best yoga poses for anxiety relief are the ones that feel good for your body and help you get grounded and find a sense of calm.

On some days, slower practices like Hatha, or gentle practices like restorative or Yin yoga, might be exactly what you need to clear your mind. Practices like these can stimulate the body's relaxation response.

On other days, faster-paced classes, such as Vinyasa, could be just as effective. Movement can help release stress and anxiety.

High anxiety levels can mean that you're not always able to begin a yoga practice with relaxation techniques.

"When there is high sympathetic nervous system activity, the mind is likely racing, which would make still postures (seated or otherwise) distressful," Knopik says.

In Knopik's experience, those who benefit from faster-paced styles of yoga tend to have developed the necessary breathwork, self-regulation, and interoception skills to remain calm and centered throughout the practice.

Without these skills, faster-paced yoga classes could be overstimulating for some people with anxiety.

"Still postures or practices need to come after some aspect of movement where nervous or anxious energy is released and individuals feel calmer," Knopik says.

More experienced practitioners may find that standing and balancing postures can help with feeling grounded and present, but can be more helpful following movement.

Seated Neck Stretch

To perform Seated Neck Stretch:

1. Begin in Easy Pose (Sukhasana), also known as a comfortable cross-legged seat.

2. Inhale and reach your right arm overhead.

3. Exhale to place your right palm over your left ear as you gently draw your head to the right and chin toward your chest.

4. Hold for 3-5 cycles of breath and release. Switch sides.

5. Optional: Place a blanket under your bottom for support, or perform this stretch seated in a chair.

Cat Pose

To perform Cat Pose (Marjaryasana):

1. Cat and Cow Pose are performed together.

2. Come to a tabletop position on your hands and knees.

3. Inhale and press into your palms, round your spine like a cat, and drop your chin, crown, and tailbone.

4. Move into Cow Pose (see below) on the exhale.

Cow Pose

To perform Cow Pose (Bitilasana):

1. From Cat Pose, exhale and drop your belly, broaden through your chest, and extend the crown of your head and tailbone upward.

2. Rotate your inner elbows forward and avoid collapsing your shoulders.

3. Inhale back to Cat Pose, and exhale to Cow.

4. Repeat the movement pattern for 5-7 cycles of breath, synchronizing each move with your breath.

Extended Puppy Pose

To perform Extended Puppy Pose (Uttana Shishosana):

1. From a tabletop position, shift your hands a little forward and knees back.

2. Press into your palms as you reach your bottom back.

3. Allow your forehead to touch your mat, and try to relax your neck and shoulders.

4. Breathe deeply in and out through your nose for 5-7 cycles of breath.

5. Optional: Place a blanket beneath your knees and shins for additional support. Or, depending on the level of your experience, you can tuck your toes under and reach your bottom up and back to come to Downward-Facing Dog (Adho Mukha Svanasana).

Half Splits

To perform Half Splits (Ardha Hanumanasana):

1. From a tabletop position, step your right foot forward into a lunge position, and tuck your left toes under. Your fingertips should be about shoulder-width distance apart, framing your front foot.

2. Slide your right foot forward until your leg is mostly straight.

3. Dig into your heel to flex your toes upward as you shift your hips slightly back to stretch your right hamstring muscle.

4. Hold for 3-5 deep breaths, then return to tabletop position. Switch sides.

5. Optional: Place your hands on yoga blocks and keep a micro-bend in your front knee. You can also soften your chin toward your chest and allow your torso to fold toward your front knee.

Seated Forward Bend

To perform Seated Forward Bend (Paschimottanasana):

1. From tabletop position, shift your bottom back toward your heels, and extend your legs out long in front of you.

2. Remove extra flesh from your sitting bones so you can feel them anchoring into your mat.

3. Sit up tall, flex your feet, and inhale to reach your arms overhead.

4. Exhale to hinge at your hips as you begin to fold your torso toward your thighs.

5. Your hands can be placed on the outsides of your thighs, calves, ankles, or feet, depending on your range of motion.

6. Drop your chin to your chest to release the back of your neck.

7. Breathe deeply, softening with each exhale, remaining here for 5-7 cycles of breath.

8. Optional: Place a rolled up blanket underneath the backs of your knees for support, especially if your hamstrings are tight.

Constructive Rest

To perform Constructive Rest (Savasana Variation Bent Legs):

1. Lie on your back with your knees bent, feet on the floor, and arms by your sides with your palms face up.

2. Adjust the placement of your feet and arms until you feel comfortable and supported.

3. Find a neutral spine by allowing for a slight curvature at the back of your neck (cervical spine) and your lower back (lumbar spine).

4. Allow for space between your chin and chest, and send your arms out a little wider.

5. Breathe deeply. This is an excellent pose for releasing your psoas muscle and resetting your nervous system. You can remain here for a few minutes or longer.

6. Optional: Widen your feet to the outside edges of your mat, and let your knees knock in toward each other.

Supine Spinal Twist

To perform Supine Spinal Twist (Supta Matsyendrasana):

1. From Constructive Rest, widen your feet to the outside edges of your mat (if they're not already there).

2. Take a deep breath in, then exhale to let both knees fall over to the right, keeping your legs staggered.

3. Gently turn your chin to the left to deepen the twist.

4. Breathe deeply into your belly, lengthening the exhales.

5. After 5-7 cycles of breath, inhale to bring your knees and chin back to their starting position, adjusting your hips if needed.

6. Exhale to drop your knees to the left, and turn your chin to the right.

7. Optional: Stack or wrap the legs.

Corpse Pose (Savasana)

To perform Corpse Pose (Savasana):

1. From Constructive Rest, extend your legs out long and adjust the position of your arms until you're comfortable.

2. Consider supporting this final resting pose with yoga props to help you feel grounded and safe. For example, you can place a folded blanket over your abdomen and another behind your head.

3. If your mind is still racing, keep your Savasana on the shorter side (1-2 minutes). If it's uncomfortable to close your eyes, keep them open and find something overhead to affix your gaze, and focus on your breathing.

4. Optional: Listen to a guided meditation or ambient music.

While many people practice yoga to relieve symptoms of stress and anxiety disorders, it should not always serve as a replacement for clinical treatment, especially when a person is experiencing panic attacks or has a severe anxiety disorder diagnosis.

While proponents may claim the "yoga high" experienced during a yoga practice can offer relief from stress and anxiety, it's important to keep in mind that this emotional state is often fleeting.

In fact, a 2021 study suggests that in some cases, mindfulness practices can backfire and actually cause anxiety to spike.

While yoga can be a healthy coping mechanism, relying on it to resolve a psychological condition is not an effective long-term solution on its own.

"Anything can become unhealthy when done to extremes," Knopik says. "Our bodies thrive with variability, both from a physiological perspective and an emotional perspective. Finding multiple ways to relieve anxiety would be most beneficial to most individuals. From a stress management perspective, the more resources we have available, the better."

A 2018 research review supports the practice of yoga for relief from symptoms associated with anxiety disorders, but more clinical studies are still needed before yoga should be used as a first-line approach to treatment.

Talk with your doctor or mental health professional to find out whether yoga is right for you. When practiced in conjunction with psychotherapy, medication, or both, yoga may be a wonderful complement to your treatment.

Yoga can enhance self-efficacy, which can be a valuable tool for calming minds and bodies to manage anxiety.

If you're ready to begin your yoga journey and explore the power of the present moment, the safest and most effective way to learn is in person with a certified yoga instructor.

If you don't have access to a yoga studio, most studios now stream classes online. Of course, countless instructional videos are available on YouTube at no cost. For example, this 20-minute yoga practice for anxiety from Yoga with Adriene is a great place to get started.

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Yoga for Anxiety: Why it Works and 9 Poses to Try

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Yoga can help relieve anxiety and stress through stimulating the nervous system. Learn about how it works, and poses to try, here.

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A panic attack is a feeling of sudden and intense anxiety.

Panic attacks can also have physical symptoms, including:

The symptoms of a panic attack are not dangerous, but can be very frightening.

They can make you feel as though you're having a heart attack, or that you're going to collapse or even die.

Most panic attacks last somewhere from 5 minutes to half an hour.

How to handle a panic attack

Professor Paul Salkovskis, Professor of Clinical Psychology and Applied Science at the University of Bath, says it's important not to let your fear of panic attacks control you.

"Panic attacks always pass and the symptoms are not a sign of anything harmful happening," he says. "Tell yourself that the symptoms you're experiencing are caused by anxiety."

He says don't look for distractions. "Ride out the attack. Try to keep doing things. If possible, it's important to try to remain in the situation until the anxiety has subsided."

"Confront your fear. If you don't run away from it, you're giving yourself a chance to discover that nothing's going to happen."

As the anxiety begins to pass, start to focus on your surroundings and continue to do what you were doing before.

"If you're having a short, sudden panic attack, it can be helpful to have someone with you, reassuring you that it will pass and the symptoms are nothing to worry about," says Professor Salkovskis.

Breathing exercise for panic attacks

If you're breathing quickly during a panic attack, doing a breathing exercise can ease your other symptoms. Try this:

breathe in as slowly, deeply and gently as you can, through your nose

breathe out slowly, deeply and gently through your mouth

some people find it helpful to count steadily from 1 to 5 on each in-breath and each out-breath

close your eyes and focus on your breathing

You should start to feel better in a few minutes. You may feel tired afterwards.

Visit the No Panic website for another breathing exercise to calm panic.

Ways to prevent panic attacks

"You need to try to work out what particular stress you might be under that could make your symptoms worse," says Professor Salkovskis. "It's important not to restrict your movements and daily activities."

Do

practice breathing exercises every day to help prevent panic attacks and relieve them when they happen

practice regular exercise, especially aerobic exercise, to help you to manage stress levels, release tension, improve your mood and boost confidence

eat regular meals to stabilise your blood sugar levels

avoid caffeine, alcohol and smoking - these can make panic attacks worse

try a panic support groups to get useful advice about how to manage your attacks - your GP can put you in touch with groups in your area

try cognitive behavioural therapy (CBT) to identify and change the negative thought patterns that are feeding your panic attacks

Is it panic disorder?

If you feel constantly stressed and anxious, particularly about when your next panic attack may be, you may have panic disorder.

People with panic disorder may avoid situations that might cause a panic attack. They may also fear and avoid public spaces (agoraphobia).

"There's no quick fix, but if your attacks are happening time after time, seek medical help," says Professor Salkovskis.

Read more about panic attacks, including personal stories, at See Me Scotland

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A panic attack is a feeling of sudden and intense anxiety. Find out ways to prevent and manage panic attacks, including breathing exercises and treatments that can help.

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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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I struggled to learn the platform and posted an empty introduction several times. I found that I know a fair amount about mental health and wellness. I guessed high on all the statistics most likely because I tend to more people with mental health issues than not. I was able to do some self-reflection during the process to see just how unbalanced and overwhelmed I had become over the past year. It was insightful and a reminder that I needed to practice what I teach.

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Need Help?

If you are thinking about suicide, please contact:

988 Suicide and Crisis Lifeline: Call or text 9-8-8 (TTY: Use your preferred relay service or dial 711 then 9-8-8.)

2-1-1, option 8, or visit 2-1-1 Texas

Crisis Text Line: Text 741741, free 24/7

Local Mental Health Authority Crisis Hotlines – Available 24/7

Mental Health Services Search

National Human Trafficking Hotline: 888-373-7888

Veterans Crisis Line: 9-8-8, press 1

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Facing a Mental Health Crisis?

If you or someone you know are faced with a mental health crisis, please call the crisis hotline of the local mental health or local behavioral health authority for your county. You may find this number by using the online mental health services search form or by calling one of the numbers below.

Crisis services are available 24 hours/7 days a week and include prompt face-to-face crisis assessment, crisis intervention services, crisis follow-up and relapse prevention services. The HHSC Crisis Services Guide (PDF) has information on various state-funded crisis services and organizations that can help connect people to resources.

LMHA Mental Health Crisis Numbers

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If you or someone you know are faced with a mental health crisis, please call the crisis hotline of the local mental health or local behavioral health authority for your county.

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Currently my license is for substance use services and I have to stay within my scope of practice. Following is the ethics for LCDC in Texas:

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(a) A licensee shall not discriminate against any client or other person on the basis of gender, race, religion, age, national origin, disability, sexual orientation, or economic condition. (b) A licensee shall maintain objectivity, integrity, and the highest standards in providing services to the client. (c) A licensee shall: (1) in addition to complying with any other applicable reporting requirements, promptly report to the department any suspected, alleged, or substantiated incidents of abuse, neglect, or exploitation committed by oneself or another licensee under this subchapter; (2) unless otherwise prohibited by law, promptly report to the department violations of Texas Occupations Code, Chapter 504 (relating to Chemical Dependency Counselors), or rules adopted under the Act, including violations of this subchapter by oneself or another licensee; (3) recognize the limitations of the licensee's ability and shall not offer services outside the licensee's scope of practice or licensure or use techniques that exceed the person's license authorization or professional competence; and (4) make every effort to prevent the practice of chemical dependency counseling by unqualified or unauthorized persons. (d) A licensee shall not engage in the practice of chemical dependency counseling if impaired by, intoxicated by, or under the influence of chemicals, including alcohol. (e) A licensee shall uphold the law and refrain from unprofessional and unethical conduct. In so doing, the licensee shall: (1) comply with all applicable laws, regulations, and orders; (2) not make any claim, directly or by implication, that the person possesses professional qualifications, licensure, or affiliations that the person does not possess; (3) include, as applicable, their current credentials when signing all professional documents; (4) not mislead or deceive the public or any person; and (5) refrain from any act that might tend to discredit the license or profession. (f) A licensee shall: (1) report information fairly, professionally, and accurately to clients, other professionals, the department, and the general public; (2) maintain complete, accurate, and appropriate documentation of services provided; (3) not submit or cause or allow to be submitted to a client or third party payer a bill for services that were not provided or were improper, unreasonable, or medically or clinically unnecessary, with the exception of a missed appointment for which notice has been given that a charge will be assessed, and as permitted by law concerning third party billing; and (4) provide responsible and objective training and supervision to interns and subordinates under the LCDC, CCS, or CTI's supervision. This includes properly documenting supervision and work experience and providing supervisory documentation needed for licensure. (g) In any publication, a licensee shall give written credit to all persons or works that have contributed to or directly influenced the publication. (h) Licensees shall respect a client's dignity, and shall not engage in, or permit their employees or supervisees to engage in, any action that may injure the welfare of any client or person to whom the licensee is providing services. The licensee shall: (1) make every effort to provide access to treatment, including advising clients about resources and services, taking into account the financial constraints of the client; (2) remain loyal and professionally responsible to the client at all times, disclose the counselor's ethical code of standards, and inform the client of the counselor's loyalties and responsibilities; (3) not engage in any activity that could be considered a professional conflict, and shall immediately remove oneself from such a conflict if one occurs; (4) terminate any professional relationship or counseling services that are not beneficial, or are in any way detrimental to the client; (5) always act in the best interest of the client; (6) not abuse, neglect, or exploit a client; (7) not engage in a sexual, personal, or business relationship with a client or a member of the client's immediate family (including any client receiving services from the licensee's employer) for at least two years after the client's services end; (8) not request a client to divulge confidential information that is not necessary and appropriate for the services being provided; (9) not offer or provide chemical dependency counseling, supervision, or related services, nor meet with a client, in settings or locations which are inappropriate, harmful to the client or others, or which would tend to discredit the profession of chemical dependency counseling; and (10) refrain from using any method or engaging in any conduct that could be considered coercive or degrading to the client or another, including, without limitation, threats, negative labeling, or attempts to provoke shame or humiliation. (i) A licensee shall protect the privacy of all clients and shall not disclose confidential information without express written consent, except as permitted by law. The licensee shall remain knowledgeable of and obey all state and federal laws and regulations relating to confidentiality of chemical dependency treatment records, and shall: (1) inform the client, and obtain the client's consent, before tape-recording the client or allowing another person to observe or monitor the client; (2) ensure the security of client records; (3) not discuss or divulge information obtained in clinical or consulting relationships except in appropriate settings and for professional purposes which clearly relate to the case, to the extent authorized by law; (4) avoid invasion of the privacy of the client; (5) provide the client his/her rights regarding confidentiality, in writing, as part of informing the client in any areas likely to affect the client's confidentiality; and (6) ensure the data requested from other parties is limited to information that is necessary and appropriate to the services being provided and is accessible only to appropriate parties. (j) A licensee shall inform the client about all relevant and important aspects of the professional relationship between the client and the licensee, and shall: (1) in the case of clients who are not their own consenters, inform the client's parent(s) or legal guardian(s) of circumstances that might influence the professional relationship; (2) not enter into a professional relationship with members of the counselor's family, close friends or associates, or others whose welfare might be jeopardized in any way by such relationship; (3) not establish a personal relationship with any client (including any individual receiving services from the licensee's employer) for at least two years after the client's services end; (4) neither engage in any type or form of romantic or sexual behavior with a client (including any individual receiving services from the licensee's employer) for at least two years after the client's services end nor accept as a client anyone with whom they have engaged in romantic or sexual behavior; and (5) not exploit relationships with clients for personal gain. (k) A licensee shall treat other professionals with respect, courtesy, and fairness, and shall: (1) refrain from providing or offering professional services to a client who is receiving chemical dependency treatment and/or counseling services from another professional, except with the knowledge of the other professional and the consent of the client, until treatment and/or counseling services with the other professional ends; (2) cooperate with the department, professional peer review groups or programs, and professional ethics committees or associations, and promptly supply all requested or relevant information, unless prohibited by law; and (3) ensure that the person's actions in no way exploit relationships with supervisees, employees, students, research participants or volunteers. (l) Prior to providing treatment and/or counseling or substance abuse services, a licensee shall inform the client of the licensee's fee schedule and establish financial arrangements with a client. The counselor shall not: (1) charge exorbitant or unreasonable fees for any service; (2) pay or receive any commission, consideration, or benefit of any kind related to the referral of a client for services; (3) use the client relationship for the purpose of personal gain, or profit, except for the normal, usual charge for services provided; or (4) accept a private professional fee or any gift or gratuity from a client if the client's services are paid for by another funding source, or if the client is receiving treatment from a facility where the licensee provides services (unless all parties agree to the arrangement in writing).

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(a) A licensee shall not discriminate against any client or other person on the basis of gender, race, religion, age, national origin, disability, sexual orientation, or economic condition. (b) A licensee shall maintain objectivity, integrity, and the highest standards in providing services to the client.

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Healing Trauma: Beyond Gangs and Prisons • Los Angeles' Homeboy Industries • BRAVE NEW FILMS

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NHS Inform. (2023, January 05). How to deal with panic attacks. Health Scottland. https://www.nhsinform.scot/healthy-living/mental-wellbeing/anxiety-and-panic/how-to-deal-with-panic-attacks#:~:text=Breathing%20exercise%20for%20panic%20attacks&text=Try%20this%3A,breath%20and%20each%20out%2Dbreath

Rethink Mental Illness. (n.d.). https://www.rethink.org/advice-and-information/about-mental-illness/learn-more-about-conditions/drugs-alcohol-and-mental-health/

Rice, A. (2021, October 26).  Yoga for Anxiety: 9 Poses to Try. PsychCentral. https://psychcentral.com/anxiety/yoga-for-anxiety

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When the client needs services not offered by the counselor or facility, referrals must be made.
When there is a conflict of interest or dual relationship, referrals must be made.
When the client is being released from counseling, referrals should be made.
The referral process is to find services that work with the client's finances, transportation, and any other considerations.
Preferably, an appointment should be made by the counselor so that it is set up for the client.

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The use of specific methods, techniques, or modalities within the practice of professional counseling is limited to professional counselors appropriately trained and competent in the use of such methods, techniques, or modalities. Authorized counseling methods, techniques and modalities may incl…

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Counseling Methods and Practices, T. A. C. Rule §681.31 (2020). https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=T&app=9&p_dir=N&p_rloc=201668&p_tloc=&p_ploc=1&pg=94&p_tac=&ti=22&pt=30&ch=681&rl=41

Texas Health and Human Services. (2023). Mental Health Crisis Services. https://www.hhs.texas.gov/services/mental-health-substance-use/mental-health-crisis-services

Treatment Planning and Implementation, T. A. C. Rule §448.804 (2020).  https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=25&pt=1&ch=448&rl=804

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(a) The counselor and client shall work together to develop and implement an individualized, written treatment plan that identifies services and support needed to address problems and needs identified in the assessment. When appropriate, family shall also be involved. (1) When the client needs services not offered by the facility, appropriate referrals shall be made and documented in the client record. When feasible, other QCCs or mental health professionals serving the client from a referral agency should participate in the treatment planning process. (2) The client record shall contain justification when identified needs are temporarily deferred or not addressed during treatment. (b) The treatment plan shall include goals, objectives, and strategies. (1) Goals shall be based on the client's problems/needs, strengths, and preferences. (2) Objectives shall be individualized, realistic, measurable, time specific, appropriate to the level of treatment, and clearly stated in behavioral terms. (3) Strategies shall describe the type and frequency of the specific services and interventions needed to help the client achieve the identified goals and shall be appropriate to the level of intensity of the program in which the client is receiving treatment. (c) The treatment plan shall identify discharge criteria and include initial plans for discharge. The Texas Department of Insurance criteria shall be used as a general guideline for determining when clients are appropriate for transfer or discharge, but individualized criteria shall be specifically developed for each client. (d) A treatment plan shall include a projected length of stay. (e) The treatment plan shall identify the client's primary counselor, and shall be dated and signed by the client, and the counselor. When the treatment plan is conducted by an intern or graduate, a QCC shall review and sign the treatment plan. (f) The treatment plan shall be completed and filed in the client record within five individual service days of admission. (g) The treatment plan shall be evaluated on a regular basis and revised as needed to reflect the ongoing reassessment of the client's problems, needs, and response to treatment. (h) The primary counselor shall meet with the client to review and update the treatment plan at appropriate intervals defined in writing by the program. At a minimum, treatment plans shall be reviewed midway through the projected duration of treatment, and no less frequently than monthly in residential programs. (i) The treatment plan review shall include: (1) an evaluation of the client's progress toward each goal and objective; (2) revision of the goals, objectives; and (3) justifications of continued length of stay. (j) Treatment plan reviews shall be dated and signed by the client, the counselor and the supervising QCC, if applicable. (k) When a client's intensity of service is changed, the client record shall contain: (1) clear documentation of the decision signed by a QCC, including the rationale and the effective date; (2) a revised treatment plan; and (3) documentation of coordination activities with receiving treatment provider. (l) Program staff shall document all treatment services (counseling, chemical dependency education, and life skills training) in the client record within 72 hours, including the date, nature, and duration of the contact, and the signature and credentials of the person providing the service. (1) Education, life skills training, and group counseling notes shall also include the topic/issue addressed. (2) Individual counseling notes shall include the goals addressed, clinical observation and new issues or needs identified during the session.

Source Note: The provisions of this §448.804 adopted to be effective September 1, 2004, 29 TexReg 2020; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842

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(a) The counselor and client shall work together to develop and implement an individualized, written treatment plan that identifies services and support needed to address problems and needs identified in the assessment. When appropriate, family shall also be involved. (1) When the client needs services not offered by the facility, appropriate referrals shall be made and documented in the client record.

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Brave New Films. (2018, August 20). Healing Trauma: Beyond Gangs and Prisons – Los Angeles’ Homeboy Industries  [Video]. https://www.youtube.com/watch?v=XvwiMJBmuQA

Phillips, L. (2020, August 31). Grappling with compassion fatigue. Counseling Today. https://ct.counseling.org/2020/08/grappling-with-compassion-fatigue/

Wagner, D. (2016, June 27). Polyvagal Theory in Practice. Counseling Today. https://ct.counseling.org/2016/06/polyvagal-theory-practice/