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Mental health awareness is increasing in society, including on social media. As a result, stigma associated with mental illness is slowly crumbling, as can be seen by the current popular hashtags #StigmaFree and #EndStigma. However, work to decrease stigma still needs to be done. Even counselors, as knowledgeable as we may be, hold biases about certain mental health diagnoses, which can lead to barriers to client care. To truly end the stigma surrounding mental health and help our clients, we must address and challenge our own stigmatized thinking.

In this article, I discuss symptoms and disorders that counselors may have negative attitudes toward, including mania, delusions and hallucinations, and personality disorders. I then discuss ways that counselors can reduce their stigma toward clients with these and other mental health issues.

Mania

Even counselors can be guilty of having negative or stereotypical beliefs about clients. For example, clinicians may refer to their clients with bipolar disorder as “manic-depressives,” thus equating clients with their diagnosis, or they may wonder, “Why can’t they just bring it down?” Such attitudes may be partly due to a lack of understanding of bipolar disorder and mania, including the symptoms and disruptions associated with them.

Clinically, mania falls under both Bipolar I and Bipolar II disorders in the Diagnostic and Statistical Manual of Mental Disorders, and it is caused by both the biochemical and neuroendocrine parts of a person’s system. A person with mania may stay awake for days on end and still have the energy to be productive. They often cannot control their manic episodes.

Mania is not always euphoric (happy energy); it can be dysphoric (angry energy). Both versions of mania can create problems, such as legal issues, financial issues, relationship conflicts and employment issues. Clients with euphoric mania may present with:

• Rapid speech
• Excessive joyful energy
• Disorganized thought patterns
• Insomnia yet does not lack energy
• Obsessive behavior patterns (e.g., shopping sprees, drug usage, binge-watching or gaming)
• Irrational beliefs centered on extreme joy or happiness that no matter what cannot be interrupted
• Loud tones in voice they do not recognize as being loud

In contrast, clients with dysphoric mania may present with:

• Excessive angry energy
• Disorganized thought patterns that can become harmful to self or others
• Hyperfocused thought patterns on wrongs done to them by others or people being out to get them
• Rapid speech
• Insomnia yet does not lack energy
• Extreme stubbornness or fixation on their way being the only way
• Screaming, yelling and vulgar language

By working to understand the patterns of behavior seen in mania, counselors can increase clients’ self-awareness and empower them to recognize the beginning of manic episodes, thus helping them to regulate their moods more consistently.

Delusions and hallucinations

Delusions and hallucinations are associated with diagnoses such as schizophrenia and psychosis, which are often stigmatized. Clients experiencing delusional thought patterns, for example, may feel invalidated or be treated differently because of their illogical thinking, loose associations and flight of ideas. In other words, counselors may treat these individuals with less empathy or as “clinical cases” instead of as people.

Clients with hallucinations may have similar experiences with mental health professionals. There are three types of hallucinations: auditory hallucinations, in which individuals hear voices or noises that are not actually present; visual hallucinations, in which individuals see things that no one else can see; and sensory hallucinations, in which individuals feel things that are not actually present. Clients may experience one or all of these types of hallucinations at the same time or separately.

As with all clients, counselors should provide clients who experience delusions or hallucinations with unconditional positive regard. In doing so, counselors will lay the foundation for developing trust and rapport with these clients.

It is common for clients who experience delusional thought patterns or hallucinations to feel isolated from loved ones and to be consistently told they are wrong. Therefore, it is important that counselors engage in deep listening and provide these clients with validation. Otherwise, counselors risk becoming another disapproving person in the client’s life, which may lead to mistrust in the mental health care system and less of a likelihood they will get the help they need.

It is critical, then, that counselors assess delusions and hallucinations without bias to help clients with these symptoms function in a healthier way in society.

Understanding personality disorders

Personality disorders may elicit strong reactions not only from the public but also from mental health professionals. For example, a counselor may exhibit fear or wariness when working with a client with a personality disorder and say, “Oh, that client scares me.” Unfortunately, personality disorders are frequently misunderstood. Rather than character flaws or personality defects, personality disorders often stem from childhood trauma, and understanding these disorders can allow us to have more empathy and compassion.

Let’s focus on narcissistic personality disorder (NPD) to illustrate this issue. Individuals with NPD may struggle with showing empathy and connecting with others and have an unrealistic sense of superiority. As a result, counselors may have negative attitudes toward these clients, viewing them as rude or uncooperative or perhaps even as “bad.” Narcissism, however, is a maladaptive defense mechanism and a way of coping and adapting, albeit in an unhealthy manner.

At times, it may be difficult to work with clients with NPD because of their aggressive and hostile behavior. It’s important, therefore, that counselors avoid personalizing such behavior. Instead, counselors should focus on helping clients work toward an understanding of how to adjust and change their behavior and gain a healthier understanding of self.

Although a person with NPD may not ever fully understand the need to change, there’s a higher chance for change if counselors respond with firm boundaries yet empathic understanding and work to create rapport and trust in the therapeutic relationship.

Challenging biased thinking

Do we need to remove all biased thinking to be a great counselor? The answer is no. As humans, we cannot remove all biased and judgment-based thinking. I’m the first to admit that I’ve had moments when biased and judgmental thoughts have popped into my head when thinking about a particular client. But just as we preach to clients about self-awareness, we too must become more aware of our thought patterns and challenge the negative and stigmatizing ones. This awareness and willingness to grow and change is what makes for a great counselor. Two areas that can help a counselor remain self-aware and in a healthy frame of mind are through practicing self-care and engaging in their own therapy.

A counselor’s job is mentally and emotionally strenuous. We’re often overworked and tired from wanting to help so many around us. This can lead to burnout and not having a healthy frame of mind to stay self-aware of one’s biased thinking, which can seep into our practice as a counselor and hurt the therapeutic alliance with clients. Thus, it is essential to take time to practice self-care to remain strong and healthy in mind and spirit.

My daily practice of self-care and meditation allows me to be aware of my own thought patterns and analyze where they are coming from. The same applies to my feelings. When I get angry, sad or frustrated at work, I stop and take a few minutes — even if it’s only five minutes — to practice mindfulness and explore the source of or reason for the feeling. Being intentional in this way helps me regain my balance and focus my attention on helping my clients.

Finding ways to decompress between sessions is also important. Booking back-to-back sessions and not leaving any time for a break often leads to burnout, which can turn into frustration and potentially even biased assessments. Although it may be difficult to find time for self-care throughout the course of a day, it is a vital source to practicing ethically.

Another way to ensure that we’re approaching our practice from a healthy frame of mind is to have our own therapist. Partaking in one’s own therapy can lead to reflection and therefore a higher level of self-awareness to remain aware of biased and stigmatized thinking. What counselors hear in counseling sessions day after day may cause them to be jaded or burned out. Engaging in their own personal therapy provides counselors with a space where they can acknowledge frustrations, transference, judgments and biases, which allows them to remain healthy in their own thinking and in their practice. In other words, personal therapy allows counselors to recognize their own vulnerabilities and stigmatized thoughts, with the potential to use that knowledge to create a healthier model for clients.

When counselors take the time to acknowledge their imperfections as humans and work to grow, change and learn, then clients will sense that genuineness and have a greater chance of developing a healthy rapport that allows them to recognize the need to grow, change and learn.  

Caitlin C. Regan is a 36-year-old mental health and addiction counselor at a treatment center in Lantana, Florida. She has been living with a mental health diagnosis since she was a teenager, and through electroconvulsive therapy and daily self-care, she has been successfully living with it for over eight years. As a teacher and counselor, she has over 15 years of experience helping those with mental health issues and addictions. Her passions include helping others, mental health, social justice, and spending time with her family, friends and two dogs. Follow her on Instagram and Pinterest @caitlins_counseling_corner or on her YouTube channel Caitlin’s Counseling Corner. Contact her at caitlinscounselingcorner@gmail.com.

The views expressed in Counseling Today are those of the authors and contributors and may not reflect the official policies or positions of the editors or the American Counseling Association.