Tag Archives: Counselors Audience

Counselors Audience

Destined for Counseling

By Melanie Padgett Powers January 25, 2024

headshot of Rick Balkin in front of a books in a bookstore

Richard S. “Rick” Balkin, PhD, LPC. Photo courtesy of Rick Balkin.

Richard S. “Rick” Balkin, PhD, LPC, was finishing up his student teaching in his last semester at the University of Missouri. In a few short weeks, he would graduate with his bachelor’s degree and become an English teacher. But after four years of study, once he began student teaching, he realized being in the classroom was not his passion.

What Balkin truly enjoyed was the interaction with his teenage students. “I liked the critical thinking that went on when you teach reading and literature and the thoughtful processes that were a major focus in English education,” he says. “It was an interesting way to connect with students.”

He started thinking about careers that would allow him to maintain a connection with adolescents. This led him to realize that becoming a school counselor may be a better fit. So, he asked his teaching supervisor: “What do you think about school counseling?” Instead of replying, “You’re about to graduate!” his supervisor said, “You’d be wonderful at that.”

Balkin stayed on at the University of Missouri to get a master’s degree in school counseling. (He earned his doctorate later at the University of Arkansas in his home state.) A few faculty suggested he should be working on the clinical side, but he stuck with school counseling at the time.

After he earned his master’s, he was hired to work at an alternative school. Six months later, he was recruited to work in an adolescent unit at a psychiatric hospital. “I thought that would be perfect. That would be centered on what I enjoyed most about working with adolescents,” he says. “And so I went and did that for seven years.”

Rick Balkin and David Kleist standing in front of their book Counseling Research

Balkin and David Kleist, PhD, who co-authored Counseling Research: A Practitioner-Scholar Approach. Photo courtesy of Rick Balkin.

Balkin is now professor and department chair of leadership and counselor education, as well as coordinator of educational research and design, in the School of Education at the University of Mississippi. Over the past 30 years, he has followed his interests and passions wherever they might take him, creating a rewarding career that has included working with teenagers in crisis, helping underserved populations and becoming an expert on practicing forgiveness.

Balkin is an ACA Fellow and the author of Practicing Forgiveness: A Path Toward Healing as well as Counseling Research: A Practitioner-Scholar Approach (the latter published by ACA). He is also a former editor of ACA’s Journal of Counseling & Development and a past president for the Association for Assessment and Research in Counseling.

Developing a Model for Forgiveness

Early in his career, at the psychiatric hospital, Balkin was working with a 16-year-old girl who had been sexually abused by her father, who was denying the allegations. During a family session with the girl and her mother, the mom turned to her child and said, “You know, as a Christian, you have to forgive him.”

Balkin looked at the mother and said, “Wouldn’t that be convenient for you?” The mom “was pretty upset with that comment, and the family session didn’t go very well,” he recalls. “But this idea of, as a Christian, you have to forgive him really bothered me.”

Balkin is Jewish and wondered if that concept of forgiveness was actually a part of Christian theology. Even if it was, he says, “it seemed like a very unsupportive and hurtful comment.” The session stuck with Balkin over the years as he continued to counsel adolescents. About five years later, at services for Yom Kippur — the Day of Atonement and the most solemn day in the Jewish calendar — he was learning more about the Jewish conceptualization of forgiveness. Judaism has three types of forgiveness: spiritual, restitution and “mechilah,” which is the wiping away of debt. Balkin thought back to his teenage client and what her mother had said.

“We reach a point that what I want from you, I’m not going to get so you don’t owe it to me anymore,” he explains. “I release you from this debt. But I still think you’re a jerk and I don’t have to have a relationship with you.” This concept of forgiveness can help people stop carrying the burden of a person owing them something that they’re never going to get, he says. He thought: “How empowering. And we don’t talk to our clients about that.”

He approached colleagues to begin working on a Forgiveness Reconciliation Model. “What this model contributes is the idea that not every relationship is repairable — and it’s not always safe to go back into a relationship that’s been harmful,” he explains. “Reconciliation has to be a separate piece of this.”

After Balkin began to present the concept and receive positive feedback, he worked on collecting data to validate the model. That became the Forgiveness Reconciliation Inventory. “It spawned an area of research and a book, and it’s just been exciting to be able to contribute to the counseling profession and client care in this way.”

Rick Balkin is holding flowers and standing with doctoral students

Balkin with University of Mississippi doctoral students in the counselor education program after attending Balkin’s TEDx talk, “How We Forgive.” Photo courtesy of Rick Balkin.

Another of Balkin’s contributions to the field is the Crisis Stabilization Scale, a clinician-rated instrument first published in 2014 for adolescent clients who were a danger to self or others. The model helps clients commit to safety, identify problems that got them to this point, process coping skills and commit to a follow-up plan, with the goal of moving to a less-restrictive level of care. Counselors can use the scale to explain to insurance companies why they should cover in-person psychiatric hospital care until the client meets specific goals related to crisis stabilization. For his work with adolescents in crisis, Balkin was awarded the 2019 ACA Extended Research Award.

Creating a Tele-Mental Health Center

Balkin is the first to admit he’s not a “technology person.” But when the COVID-19 pandemic hit in 2020, counselors could no longer meet clients in person, plus graduate students were unable to meet their clinical experience requirements.

Balkin proposed creating a tele-mental health solution at his university. He obtained a grant from Mississippi’s Governor’s Emergency Education Response Fund, which was supported by federal COVID-19 emergency response money, to create a tele-mental health center on the University of Mississippi campus. The center provided mental health services across the state to public school children — who were unable to access school counseling services during lockdown and virtual schooling. The funding also helped build the tele-mental health infrastructure and train counseling students on how to use it and meet their certification requirements. (Balkin secured external funding after the governor’s grant ended to keep the center going.)

Even though face-to-face counseling is now available, 52% of the center’s counseling is still done virtually. It has expanded mental health counseling accessibility in Mississippi, one of the most economically disadvantaged states in the country, particularly the Delta region. “Being able to provide counseling services for a very disenfranchised population has been really important for the state of Mississippi,” Balkin says. “Places that are three, four and five hours away, we can deliver both individual and even small-group activities.”

In addition, it’s less burdensome on families. “What’s wonderful is we don’t have to pull a kid out of class anymore. They can come home, get on their Chromebook or iPad, and we can provide counseling right there,” he says. “And parents don’t have to take off work, which was always a problem.”

A Love for Teaching after All?

Balkin grew up in Little Rock, Arkansas. It wasn’t an easy childhood, and he admits he could have benefited from some counseling. He had a serious seizure disorder, and his medication left him uncoordinated. He was singled out and bullied often. When he was 7, his mom signed him up for taekwondo, thinking it would help with his coordination and self-esteem.

Rick Balkin and his daughter earning a new belt in Brazilian jiu-jitsu

Balkin and his daughter, Isabel Balkin, getting promoted in Brazilian jiu-jitsu. Photo courtesy of Rick Balkin.

Balkin enjoyed taekwondo immediately, although he was a bit frustrated at his slow progress. One of his three older brothers, whom he really respected, challenged him to get his black belt. That gave Balkin a goal. Today, he’s an eighth-degree black belt (ninth degree is the highest), and he also trains in Brazilian jiu-jitsu, where he holds a brown belt.

In high school, Balkin competed in taekwondo tournaments and taught kids and adults at the taekwondo studio. “It’s where I felt very different; I was treated very differently. It was kind of my haven. It was through that that I learned how to connect with people because that wasn’t happening socially for me at school,” he says.

His taekwondo teaching experience led him to pursue a teaching degree in college — where he discovered his true passion was not teaching but working with adolescents. Balkin eventually made his way back to the classroom, however, this time in higher education. Throughout his academic career, he has taught several counseling courses, particularly ones on research methods and statistics. But, as he explains, “I’m not teaching English. I’m teaching counseling. That’s a lot more fun.”

Kimberly Frazier: Presidential year in review

Counseling Today May 23, 2023

Headshot of Kimberly Frazier

ACA President Kimberly Frazier, 2022-2023 (Photo courtesy of Kimberly Frazier)

June marks the end of Kimberly Frazier’s term as the 71st president of the American Counseling Association. Frazier has accomplished much over these past 12 months. Surrounded by supportive colleagues, she has worked hard to move the counseling profession and ACA forward with her three spotlight initiatives: justice, equity, diversity and inclusion (JEDI); wellness and self-care; and mentoring.

Making diversity and inclusion a priority

Kimberly Frazier presenting at the ACA Conference & Expo

Kimberly Frazier presents the welcome address to the Korean Counseling Association during the ACA Conference & Expo. (Photo courtesy of Alex Webster/Pinpoint National Photography)

One of Frazier’s passions — both professionally and personally — is creating resources and advocating for marginalized people, so it’s not surprising that she put the JEDI initiative front and center during her ACA presidency.

In February, Frazier, along with Rheeda Walker, discussed Black mental health and wellness on a special episode of ACA’s podcast, The Voice of Counseling. And at the 2023 ACA Conference & Expo, Frazier announced that she had created a new award honoring Thelma Daley, who was the first Black woman to serve as ACA president (1975-1976).

“Dr. Daley has not only inspired me, but she helped pave the way to leadership for so many others,” Frazier says. “The Dr. Thelma T. Daley Advocacy and Equity Award will recognize our member advocates who have made a real difference by advocating on behalf of Black and Brown communities.”

Advocating for counselor wellness

Frazier acknowledges that counselors cannot be leaders, advocates, clinicians and mentors without first learning to take care of themselves. The first step, she says, is often being aware of one’s own personal wellness and self-care needs.

“We cannot pour from an empty cup as counselors,” Frazier reminds her colleagues.

Frazier worked closely with ACA to select a Counseling Awareness Month theme that focused on wellness and self-care. This year’s theme, “Get Fit for Your Future,” reminded counselors to prioritize keeping their physical, emotional, social, spiritual and mental health “in shape.” ACA kicked off Counseling Awareness Month with a workout video designed for counselors on April 1 and a Peloton ride with Frazier and ACA CEO Shawn Boynes on April 8. And all month long, counselors took advantage of curated resources on the ACA website that aimed to help them “get fit” for their future.

Focusing on mentoring

Throughout her presidency, Frazier has emphasized that mentoring is key to developing a confident and skilled group of future advocates and leaders.

On June  21, she will lead a virtual mentoring summit, which features a keynote address and two speaker sessions on successful mentoring, how to select a mentor and the benefits of mentoring. This event will help program leaders and mentors discover new ways to execute their mentoring efforts, and it will help new professionals and students learn best practices in finding a mentor and fostering a healthy mentoring relationship.

ACA President Kimberly Frazier and students from HBCU Cares at the 2023 ACA conference

Kimberly Frazier with the HBCU Cares students at the ACA Conference & Expo: Denzell Brown, Brittany Hinkle and Serena Bradshaw from Howard University; Brittney Watson Greene from North Carolina Central University; Tyreeka Williams, Kacie Rebe Dentleegrand and Allyson Graham from North Carolina A&T State University. (Photo courtesy of Alex Webster/Pinpoint National Photography)

Frazier was also able to bring together two of her initiatives — JEDI and mentoring — by helping ACA form a partnership with HBCU Cares, an organization that aims to raise awareness of and access to mental health for diverse students at historically Black colleges and universities (HBCUs). Through a partnership between ACA, HBCU Cares and the Substance Abuse and Mental Health Services Administration, a group of HBCU Cares students was able to attend the ACA conference for the first time.

“Partnerships such as this will help raise ACA’s visibility outside of the counseling realm and connect us with entities that lacked awareness about the importance of counseling and the counseling profession,” Frazier says.

Inspiring others

Through her presidential spotlights, speaking engagements and monthly Counseling Today columns, Frazier has motivated, inspired and challenged her colleagues to push themselves to be better counselors, advocates and leaders for the profession and the communities they serve. In her Counseling Today columns, Frazier went beyond simply telling readers what JEDI, wellness and mentoring should look like; she also encouraged her colleagues to put her advice into action by ending each column with a challenge related to one of her presidential initiatives.

ACA President Kimberly Frazier and CEO Shawn Boynes on stage at the 2023 ACA Conference

Kimberly Frazier and Shawn Boynes deliver opening remarks at the ACA Conference & Expo. (Photo courtesy of Alex Webster/Pinpoint National Photography)

Frazier continues to challenge and inspire those in the profession and organization. She fondly recalls watching Beverly O’Bryant speak during the opening session of the 2002 ACA conference. Seeing O’Bryant on stage in that leadership role illustrated to Frazier what could be achieved through hard work and stellar mentorship.

“Seeing her made me feel seen,” Frazier recalls. “I hope that I can inspire another counselor to see themselves inside of ACA working as a leader and an advocate, just as I was inspired when I watched Dr. Beverly O’Bryant speak during the opening session of the ACA conference many years ago.”

Throughout her presidency, Frazier has also reminded her colleagues, “The advocacy continues.” That message will serve as a guiding light for ACA and the counseling profession even after Frazier’s presidency comes to an end this June.

Fatphobia: How can counselors do better?

Compiled by Bethany Bray November 23, 2022

Stop and think for a moment: Have you ever seen a plus-size Barbie doll or rooted for a romantic hero who wasn’t thin?

Kaitlyn Forristal, a licensed professional clinical counselor, poses this question to illustrate the way fatphobia and weight stigma saturate our culture and society.

“We are programmed from a very young age to associate fatness with bad things … [and] counselors are not immune from socialized viewpoints and messages,” says Forristal, an assistant professor of clinical mental health counseling at New England College in Henniker, New Hampshire.

It’s up to counselors, therefore, to examine their own feelings and assumptions about weight and body size to keep from passing them on to clients in therapy, she stresses.

Forristal studied fatphobia’s influence on diagnosis decisions made by counseling graduate students in her 2018 doctoral dissertation; fatmisia is an area of research and specialty for her. Counseling Today sent her some questions via email to learn more about how weight stigma can show up in the therapy room and what counselors can do to dismantle it — both in themselves and in their clients.

How might fatphobia and weight stigma show up in counseling? Misdiagnosis is one area, but what else?

Yes, misdiagnosis is a concern due to a societal belief that “obesity” is a medical disease. Aside from diagnosis and treatment, counselors are also at risk for projecting their own (potentially negative) beliefs about their bodies and health status onto their fat clients. Despite what a clinician may assume, many fat clients are comfortable in their bodies and have no intention of changing them.

It could also be dangerous for counselors to assume that a fat person’s presenting issues, such as body image struggles, anxiety, depression or other mental health concerns, will be alleviated if the client loses weight. It is likely that fat people have internalized fatphobia — a set of negative beliefs about themselves because they are fat — and believe that losing weight will help them to solve their problems. While this may be true to some extent, losing weight cannot repair relational issues or make up for [brain] chemical imbalances.

If a person is struggling with the stigmas associated with being fat, or expresses hatred of themselves for being fat, attempting to change their body is not the solution. We eradicate prejudice by addressing the socialization of fatphobia and working to make our society safer and more inclusive for everyone.

What would you want counselors to know about approaching the assessment and intake process in a nonstigmatizing way? How can counselors ask about weight or weight loss, eating habits, etc., without a client feeling they are being shamed or judged?

Using the same intake measures and assessments with both fat and thin clients is the best way to approach this; don’t assume that a fat person overeats or that a thin person exercises regularly.

Consider why you may want to ask about weight loss or eating habits: Is it to confirm your suspicion that a fat client doesn’t get enough cardio or because you [assume] that their weight loss/gain is a symptom of depression?

If a fat client reports on an intake form or during an interview that they struggle with self-esteem due to their body size, want to lose weight or have poor body image, counselors should address that the same way they would with a thin client. If a new client doesn’t mention struggling with these things but happens to be fat, they are probably there for other reasons and you don’t need to ask about weight loss or eating habits.

Counselors don’t need to be afraid to discuss body size, fatphobia and marginalization with fat clients, but they also don’t need to broach this with a client just because they think someone may have an issue solely because of their body size.

How might counselors be making assumptions that someone who doesn’t fit society’s norms for shape and size is unhealthy and/or somehow to be blamed for their challenges? How might this bias creep in without counselors realizing?

It is an unfortunate societal belief that we can tell someone’s health status by looking at them. We see this all the time with news coverage of the “obesity epidemic” (spoiler alert: fat people have always existed!) and dehumanizing b-roll [news footage] of [faceless] fat people walking around and living their lives.

Something that is really strange about society if you think about it is the notion that others’ bodies are for us to comment on or have an opinion about. How often do you see someone who has changed size (lost or gained weight) and made an assumption about them, whether they have “let themselves go” or are now healthier due to a smaller body? When you run into someone you haven’t seen in a while and they are smaller, do you automatically congratulate them or tell them how great they look? Each time you do this, you are making an assumption that they lost weight intentionally and that it is worth celebrating that there is now less of them.

There are many medical conditions that are often attributed to fat people (diabetes, heart disease, sleep apnea) that medical research doesn’t support. The average size person in the United States is “overweight,” so it is likely that many findings that fatness is a cause of these medical conditions are misinterpreted when fatness is correlated to these conditions. It is important to be good consumers of research and pay attention to who is putting out studies that demonize fatness (I’m looking at you, Weight Watchers!) and who the intended audience is.

Researching the history of the body mass index (BMI) can help as well. Considering that the BMI is still used in western medicine for pathology and treatment of patients is baffling and is not rooted in accuracy or health outcomes. The BMI is unnecessarily vague (e.g., “overweight” — over what weight?) and doesn’t account for muscle mass or many other confounding factors. Some of the most elite athletes in the world are “morbidly obese” according to the BMI.

It was never created to be used the way that it is now, and aside from the harmful labels it puts onto people’s bodies, it creates real issues for mental health care treatment. For example, due to the BMI categories, many fat people have difficulty receiving treatment for eating disorders, which is detrimental to client and community health and to the profession of counseling.

What do counselors need to do to check themselves and unlearn old patterns and assumptions about weight and body size? How can counselors do better?

Unlearning negative beliefs about fat people is a similar process to unlearning socialized beliefs about other marginalized identities (LGBTQIQA+ community, BIPOC [Black, Indigenous and people of color], disabled people). There is nuance to this in the United States as we are an individualistic society who believe that for the most part, people get what they deserve or work for.

Therefore, fatphobia falls into a category with other social issues like poverty where we feel more comfortable attributing blame to individuals that we believe can change their status if they only tried and worked hard enough for it. Poor people can just work harder or get better jobs to “pull themselves up from their bootstraps,” or fat people could lose weight if they only had more self-control. Obviously, neither of these things are true for the vast majority of people facing this discrimination, but the societal belief that we can change our circumstances continues to harm those in our communities.

Counselors can do better by speaking out about these things and advocating for the rights and dignity of fat people. It should come as no surprise that bias against fat people is rooted in racism and xenophobia.

Fatmisia is also rooted in capitalism; the weight loss industry was worth $72 billion in 2018. Selling weight loss programs, weight loss surgeries and weight loss-focused fitness programs is a business that is only viable because people buy into the notion that fatness should be avoided at all costs (literally).

Having this information is helpful for counselors to (a) reconceptualize the way they feel about their own bodies, (b) provide validation and psychoeducation for clients struggling with body image or other weight-related issues and (c) advocate for changes in the way that others in society view and relate to fat people.

How can counselors support a client who names weight loss as a goal in counseling? What should a counselor’s role be in this situation?

A counselor’s role is always to support their client in treatment, and there are many valid reasons for clients to want to lose weight: to be safer in society by living in a smaller body, because a family member has expressed concern for their weight, a medical provider suggests it for overall health, or as a requirement for a certain procedure, etc. However, counselors are not medical providers, physical therapists, dietitians, etc., and should refrain from providing any medical advice as this is outside of our scope of practice and unethical.

It can be easy to automatically support a client who wants to lose weight because we believe that a fat body is always an unhealthy one, but this is not the case and could cause harm. Most research on dieting shows that intentional weight loss does not work and that only 5% of dieters maintain their weight loss for an extended period of time; most dieters gain back the weight they lost and more due to the metabolic disruption of putting one’s body into starvation mode.

Counselors can, of course, ask about the reasons the client is bringing this up in session: Are they having body image concerns, experiencing disordered eating or relational problems? These are issues that counselors are trained and qualified to help with. Exploring these issues may reveal the deeper issue that a client has an eating disorder or is being verbally/emotionally abused by a partner. A counselor’s role in either of these cases would be to explore options for the client and set goals in treatment. If a counselor has training/knowledge in this area, this is a good opportunity to self-disclose their own body image concerns and ask the client if they would like [the counselor] to share with them some information about weight loss, the diet industrial complex, etc., that may help them reframe these issues.

What should counselors avoid doing or saying in sessions with clients to keep from harming them with weight stigma?

The easiest way counselors can know how to speak about clients’ bodies is by asking them! Some people prefer to describe themselves as fat because it is merely a descriptive word like tall, dark-skinned, etc. For others, there is such a negative connotation with the word fat (and a lot of harm associated with it) that they prefer other ways to describe themselves.

Counselors should avoid making assumptions about fat clients that they wouldn’t make about their thin clients, such as [whether] they overeat or binge eat, do not exercise enough, hate their body, etc. Practicing weight neutrality, or making no assumptions (good or bad) about a client’s weight or body size, is a great start.

It is also imperative that counselors resist the notion that fat people can or should lose weight to avoid stigma and marginalization due to their body size. We would not expect a little person to just grow taller to access the world with more ease, and we should not project this onto fat people either. Humans have always come in all shapes and sizes and being fat is just one way of having a body — it is that simple.

Michael Poley/canweallgo.com


See more on this topic in a feature article, “Pushing back against fatphobia” in Counseling Today’s upcoming December magazine.


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


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

A beginner’s guide to alexithymia

By Jerrod Brown November 8, 2022

Alexithymia is a complex, subclinical phenomenon characterized by cognitive-affective functioning impairments that can affect as many as 10% of the general population. Typically, individuals with alexithymia struggle to recognize, identify and describe their feelings. This often includes trouble discerning between emotions and physiological sensations. Because alexithymia is a known risk factor for a wide range of psychological and physical health problems, this psychological construct has significant implications for professionals working in the field of mental health. In fact, the failure to accurately identify the presence of alexithymia can significantly impact the intake, screening, goal-planning and therapeutic processes. Therefore, mental health professionals should become familiar with the wide array of disorders, traits and experiences often associated with elevated rates of alexithymia. 

Unfortunately, many mental health professionals lack the necessary training and expertise to accurately identify and effectively treat the unique and complex symptoms of alexithymia. A strong contributor to this predicament is the lack of training and educational programs that offer workshops and coursework dedicated to this important and complex topic. The goal of this article is to provide mental health professionals with a basic introduction to alexithymia by highlighting information in four essential areas: (a) symptoms and red-flag indicators, (b) diagnostic comorbidity, (c) screening and assessment and (d) intervention and treatment considerations.

Symptoms and red-flag indicators

Symptoms of alexithymia can vary from person to person and are often influenced by many neurological, biological and psychosocial factors.

The cognitive factors associated with alexithymia can include: 

  • Deficits in the regulation of thoughts, emotions and bodily processes 
  • Difficulty with introspection
  • Inhibition and impulsivity issues
  • Limited imagination and fantasy life
  • Constricted patterns of thought
  • Reliance on concrete thinking almost to the exclusion of symbolic thinking
  • The affective factors associated with alexithymia can include:
  • Blunted or limited personal experience of emotions
  • Difficulty identifying and describing emotions
  • Emotion dysregulation
  • Failure to identify the causes of personal feelings
  • Inability to seek and use support systems to help with emotional problems
  • Limited use and understanding of verbal and nonverbal emotional cues
  • Poor emotional awareness
  • Emotional avoidance and suppression 
  • Difficulty distinguishing between emotions (e.g., telling the difference between anxiety and anger)
  • Weak affective theory of mind
  • The social factors associated with alexithymia can include:
  • Interpersonal communication characterized by coldness, flatness and a lack of emotion
  • Lack of empathy
  • Loneliness
  • Nonassertiveness
  • Perspective-taking deficits
  • Social conformity
  • Verbal and nonverbal communication deficits
  • Weak social attachments
  • The physiology factors associated with alexithymia can include:
  • Physical sensitivity to the experience of different sensations
  • Tendency to mistake affective responses as physiological experiences or dysfunctions

Diagnostic comorbidity

Alexithymia often co-occurs with a diverse array of psychiatric, trauma-based, neurocognitive, neurodevelopmental and substance use disorders, so it is likely that mental health professionals provide services to clients impacted by alexithymia on a regular basis. In particular, individuals with alexithymia are quite prone, but not limited, to presenting with another disorder that features affective symptoms. It is important to note that alexithymia can be viewed as a risk factor for psychopathology as well as other conditions. The following highlights some mental health conditions often associated with alexithymia.

Substance use and other addictive disorders. The prevalence rates of alexithymia are higher among individuals with substance use and addictive problems than the general population. In addition, individuals with alexithymia appear to be at risk for more severe alcohol-related problems than those without alexithymia. This has led some researchers to posit that alexithymia could place a person at risk for alcohol use problems. Failure to consider the role of alexithymia in alcohol use could undermine the effectiveness of any interventions.

Stress-related disorders. Research has consistently linked alexithymia to physiological stress markers as well as stress-related disorders. For instance, individuals with alexithymia often exhibit elevated levels of chronic stress on measures of cortisol awakening response and cortisol secretion during the dexamethasone suppression test. Other evidence includes increases in inflammation and atypical immune responses, which could be consequences of prolonged exposure to stress.

Posttraumatic stress disorder. Posttraumatic stress disorder (PTSD) is a condition characterized by heightened reactions, anxiety, intrusive memories and nightmares, and other-related symptoms. The onset of PTSD is precipitated by exposure to a traumatic event (e.g., violence, accidents, natural disasters). Some of the same traumatic experiences that lead to PTSD could also contribute to the development of alexithymia. As a result, mental health professionals are encouraged to screen for alexithymia in clients presenting with PTSD.

Insecure attachment. Research has found higher rates of alexithymia among people with insecure attachment patterns compared to people with secure attachment patterns. Insecure attachment patterns may also cause the impacted individual to experience trust issues, fears of abandonment, general discomfort and decreased coping abilities. And both insecure attachment patterns and alexithymia have been linked to increases in emotional and behavioral problems. Therefore, attachment-based therapists are encouraged to become informed about alexithymia. 

Traumatic brain injury. Traumatic brain injury is temporary or permanent brain damage caused by a blow or some other wound to the head. Common symptoms of traumatic brain injuries include impulsivity, aggression, emotion dysregulation and poor coping skills when under duress. Research shows that many people who suffer from a traumatic brain injury also experience alexithymia.

Neurodevelopmental disorders. Alexithymia has also been found to be elevated among people diagnosed with  neurodevelopmental disorders, including attention-deficit/hyperactivity disorder, autism spectrum disorder, fetal alcohol spectrum disorder, and intellectual and developmental disability. Routine screening for alexithymia among people diagnosed with a neurodevelopmental disorder may lead to improved treatment outcomes.

Hypothalamic-pituitary-adrenal axis dysfunction. The hypothalamic-pituitary-adrenal (HPA) axis may play a role in alexithymia. This system is responsible for regulating stress responses and ensuring the body adjusts to evolving environmental conditions. Exposure to stressful situations can elicit chronic hyperactivity of the HPA axis. In such instances, a person becomes at risk for stress-related physical and mental health problems. Because of the potential connection, I recommend counselors also become informed about the HPA axis when learning about alexithymia. 

Somatic symptoms. Individuals with alexithymia tend to score higher on measures of physical distress than the general population. These physiological differences could help explain the higher prevalence of anxiety and depression symptoms among those with alexithymia. During times of distress, people with alexithymia may experience and complain more about psychosomatic-based symptoms.

Dissociative tendencies. Dissociation occurs when there is a disconnection among a person’s cognitions, emotions and actions. The presence of dissociation could play a role in the emergence of alexithymia or vice versa. This is particularly salient in people who have experienced trauma such as neglect and abuse. In such cases, the development of dissociation and alexithymia could serve as an adaptive response that prevents a person from being overwhelmed.

Sleep disturbances. Individuals with alexithymia often report comorbid sleep problems. These can include difficulties with staying awake or falling and staying asleep. Emotional problems that are similar to alexithymia have also been observed among individuals experiencing sleep deprivation. 

Language problems. Individuals with alexithymia often struggle with verbally expressing their own emotions. In addition, individuals with alexithymia have trouble comprehending the verbal communications of other people. Therefore, problems with language processing could be an important causal influence on the development of alexithymia.

Executive dysfunction. Individuals with alexithymia commonly exhibit deficits in executive function, which is a set of cognitive, affective and behavioral skills that enable a person to plan and perform specific tasks. In particular, cognitive flexibility, inhibition and working memory are often described as the primary aspects of executive function. It is important to note, however, that many other constructs fall under the umbrella of executive function. The symptoms of alexithymia and deficits in executive function may be exacerbated by various forms of extreme stress and trauma. When this occurs, it can significantly impede goal achievement and adaptive functioning.

Immune function dysregulation. A growing number of studies have reported an association between alexithymia and immune system dysregulation. The same stressors that cause alexithymia could also alter how the immune system functions. A grave consequence of immune system dysregulation includes proneness to a diverse array of psychosomatic illnesses. Encouraging the client with alexithymia to maintain regular contact with their health care provider is warranted.

Emotional regulation deficits. Individuals with alexithymia often present with emotional dysregulation issues. For example, individuals with alexithymia usually struggle to express or understand their feelings and the feelings of others. As a result, many mistake the symptoms of alexithymia as a lack of empathy. Consequences of emotional dysregulation include difficulties with establishing and maintaining relationships across the life span. In some instances, this could lead to a breakdown in the therapeutic alliance. 

Worry and rumination. Individuals with alexithymia typically experience high levels of worry and rumination. Worry is generally distinguished by fears of danger, whereas rumination is characterized by thoughts about loss and failure. These repetitive cognitive processes are common in internalizing disorders (e.g., anxiety, depression).

Deliberate self-harm. Empirically based research has found an association between alexithymia and a history of substance abuse and deliberate self-harm. Such self-injurious behaviors could be an attempt to cope with emotional dysregulation, which is frequently exacerbated by alexithymia.

Suicide risk. Alexithymia could serve as a risk factor for suicidal behaviors. Individuals with alexithymia are prone to depression, anxiety and other affective problems, all of which are also predictors for suicidal behaviors.

Screening and assessment

Clinicians should carefully screen for alexithymia prior to the development of mental health and substance use treatment plans. The Toronto Alexithymia Scale (TAS-20) is one instrument counselors can use to screen for alexithymia. The TAS-20, which is commonly used in neuroscience studies, is a 20-item, self-report questionnaire that measures skills in the areas of emotion recognition, emotion description and perspective-taking. Several empirically based articles have been published pertaining to the efficacy of the TAS-20.

When screening, clinicians should watch for increased symptom reporting. Individuals with alexithymia are prone to confusing emotions and feelings for physiological problems with their bodies. In turn, this group is disproportionately likely to overreport and seek medical care for physiological problems. This is another example of maladaptive coping in the context of alexithymia. 

Ground Picture/Shutterstock.com

As mentioned in the previous section, individuals with elevated stress and anxiety, burnout, or a history of trauma are predisposed to alexithymia. Therefore, systematic screening and assessment for alexithymia is encouraged in these groups. Trauma-informed counselors would also benefit from learning about alexithymia. 

Emotional numbing and emotional suppression are two other areas that mental health providers should consider during the intake and treatment planning process. Emotional numbing is the affective process of minimizing or eliminating the experience of feelings. Like alexithymia, this could be viewed as a temporary coping strategy that is deployed to protect against the consequences of trauma. And emotional suppression is a common way that individuals with alexithymia regulate their feelings. This may be traced back to difficulties in recognizing and understanding emotions that characterize alexithymia.

It is also critical that mental health professionals obtain information from collateral informants when screening for alexithymia. In many instances, the client may lack insight into their own symptoms, which renders self-reported information as insufficient. So conferring with family members, friends and co-workers can help illuminate the nature of the client’s symptoms and their impact on global functioning. In addition, consulting with any other professionals that work with the client can be informative.

Intervention and treatment considerations

Individuals with alexithymia typically have worse mental health treatment outcomes than those without alexithymia. In an effort to address this quandary, research has focused on identifying interventions that help improve outcomes for individuals with alexithymia. This section highlights potential considerations that mental health professionals should make when treating alexithymia.

The symptoms of alexithymia likely undermine the development of therapeutic alliances with mental health professionals. Specifically, difficulties with recognizing and describing affective experiences as well as perspective-taking make it difficult to develop interpersonal closeness with others. 

In addition to limiting the development of the therapeutic alliance, alexithymia could be associated with poor treatment engagement. In combination, these suboptimal outcomes in the therapeutic process contribute to an increased likelihood of negative short- and long-term treatment outcomes in individuals with alexithymia.

The difficulties that alexithymia presents in terms of the therapeutic alliance and treatment engagement are particularly salient in substance use treatment settings. Clients with alexithymia may be dependent on the use of substances to cope with the affective symptoms of their condition. The failure to account for and address alexithymia during the therapeutic process decreases the likelihood of good treatment prognosis.

Individuals with alexithymia are also prone to poor treatment attendance and adherence, which can be expected among clients with poor treatment engagement. Thus, failure to complete treatment programs and relapses are common in clients with alexithymia.

The research literature on the treatment of alexithymia has grown in recent decades, and there is now a substantive list of interventions worth considering when treating clients with alexithymia (see table below). Psychoeducation offers one promising treatment option for clients with alexithymia. A limited but growing body of research indicates that supportive and psychoeducational approaches to therapy may be effective in treating alexithymia. Interpretive approaches to therapy, however, appear to be less effective with this population.

Alexithymia intervention table by Jerrod Brown

Mindfulness training may also be a critical component to incorporate in the treatment of alexithymia. For instance, mindfulness-based training has been linked to increased emotional effectiveness. So using mindfulness-based approaches may result in improved emotional awareness among clients experiencing alexithymia. 

Music therapy also holds promise as an intervention for clients with alexithymia. This therapeutic approach is particularly well suited for clients who struggle to describe thoughts and feelings with words. Thus, clients with alexithymia may find it easier to express their emotions in music therapy.

Individuals with alexithymia generally struggle with emotional clarity, which is the ability to recognize and understand the causes of one’s emotions. Development of emotional clarity could help a client with alexithymia not only benefit from treatment but also protect against victimization in their personal life.

Clinicians can also help clients with stress management. A common risk factor for alexithymia is the experience of extreme stress. It is unsurprising, then, that individuals with alexithymia often struggle with stress management. Thus, the development of stress management skills remains a critical target in any intervention for clients with alexithymia.


Alexithymia is a complex and important topic all mental health clinicians need to know. Since elevated rates of alexithymia are found in a host of trauma-based, substance use, neuropsychiatric, neurocognitive and neurodevelopmental disorders, it is likely that mental health professionals will encounter clients impacted by this subclinical, cognitive-affective deficit on a regular basis. Unfortunately, in my experience, few professionals working in the field of mental health have received sufficient education and training pertaining to the topic of alexithymia. 

I strongly encourage all helping professionals to become informed about alexithymia. Here are three ways counselors can begin this process:

  • Seek professional consultation from recognized alexithymia experts.
  • Review key journals in the field on a regular basis to stay abreast of the latest peer-reviewed research on alexithymia.
  • Continue to seek education and training on the best ways to screen for alexithymia and the best intervention techniques to use with clients who struggle to identify and describe their emotions.



Important facts about alexithymia 

Here are some important reminders mental health professionals need to consider when learning about the topic of alexithymia: 

  • Alexithymia is a threat to emotional, social, and physical health and well-being.
  • Alexithymia is not considered a mental health disorder and is mentioned only once in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. 
  • Alexithymia is a trait found elevated among people diagnosed with neuropsychiatric, neurocognitive, neurodevelopmental, trauma and stressor, and substance use disorders.
  • Numerous empirically based articles have been published on the topic of alexithymia. 
  • Alexithymia can amplify stress and its impact on emotional, social, behavioral and physical health.
  • Clients with alexithymia have difficulty understanding, processing, recognizing and describing emotions.
  • During times of increased stress, worry and conflict, people impacted by alexithymia frequently experience an increase in psychosomatic-based symptoms.
  • Alexithymia can impede the therapeutic alliance, especially when mental health providers lack an awareness and understanding of this topic.
  • When becoming trauma informed, it is also important to become alexithymia informed. 
  • Professionals are strongly encouraged to seek out additional training and consult with experts to better understand the implications of alexithymia within mental health and substance use treatment settings.
  • Academic-based institutions and continuing education training programs are encouraged to offer curriculum and workshops pertaining to the mental health implications of alexithymia.



Jerrod Brown is an associate professor, program director and lead developer for the master’s degree in human services with an emphasis in forensic behavioral health and in trauma, resilience and self-care strategies for Concordia University in St. Paul, Minnesota. He has also been employed with Pathways Counseling Center in St. Paul for the past 19 years. Contact him at Jerrod01234Brown@live.com.


Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.


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.

Incorporating clients’ faith in counseling

By Lisa R. Rhodes November 2, 2022

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

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

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

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

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

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

An evolving practice

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

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

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

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

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

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

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

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

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

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

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

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

Know thyself, know the client 

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

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

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

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

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

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

Faith and self-disclosure

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

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

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


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

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

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

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

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

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

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

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

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

Broaching the topic

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

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

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

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

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

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

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

Blending faith and counseling

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Overcoming challenges

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

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

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

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

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

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

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

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

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

Be curious

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

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

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

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

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

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

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

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

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

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



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


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