Teletherapy Tips: Best Practices for Engaging Behavioral Health Consumers over Phone and Video

The COVID-19 crisis has led to a paradigm shift in the way behavioral health care is provided. With in-office visits now inadvisable, care providers have begun to adopt telehealth technologies on a scale that’s never before been seen. While this rapid change has allowed mental health professionals to continue serving the needs of their clients, it has also created many questions about the most effective way to provide care from a distance.

Perhaps the biggest challenge of telemental health care is how it alters the dynamic of the consumer-provider relationship. In a virtual session, nonverbal communication is more difficult to utilize and detect, which places a greater emphasis on the words spoken in the session. The environment is also less controlled than in an office setting, which makes it harder for participants to focus and allows more opportunities for distraction. Finally, the balance of power is different in a virtual session, as consumers have more agency to ignore provider recommendations, end the session prematurely or skip it altogether.

These issues can be compounded if care providers are simultaneously struggling to adapt to remote work. Working remotely comes with unique advantages and challenges, and many behavioral health professionals may be unprepared for the realities of working outside the office. In addition to effectively engaging consumers over phone or video chat, providers must also take care to manage their environment and behaviors in order to be successful under these new circumstances.

The good news is that telemental health sessions can be just as effective and achieve the same outcomes and as in-person care when conducted correctly. Kristen Yost, a therapist for Cummins’ Marion County school-based program, has developed her own methods for working around many common telehealth difficulties. We spoke with Kristen to learn what obstacles you should expect during a telehealth session, how to engage consumers under the altered dynamics of virtual care, and what remote work practices will help you excel under the new telehealth paradigm.

Best Practices for Engaging Consumers via Telehealth

Kristen Yost, LMHC, School-based Therapist at Cummins Behavioral Health
Kristen Yost, LMHC, school-based therapist at Cummins Behavioral Health

As mentioned above, bringing the consumer-provider relationship into the virtual realm changes the nature of this relationship. Consumer engagement is a continual concern even in face-to-face treatment, but a lapse in engagement during virtual treatment can be more damaging and more difficult to recover from. Therefore, providers must take special measures to keep consumers engaged with treatment when sessions are being conducted virtually.

There are several points in the virtual treatment process where consumer engagement can dwindle. First, consumers may be reluctant to engage with virtual services at all, which could be due to anxiety about the telehealth process or the belief that virtual services are not necessary. “If they were engaged in services before, it would first be helpful to identify the underlying reason for this change,” Kristen says. “It may be anxiety about transitioning to teletherapy, a dislike for talking on the phone, or concern that others may overhear conversations. If these are the barriers, then identifying and working through them would be therapeutic. Otherwise, it may be helpful to work with the consumer to revise or identify new goals, as changes in the environment and daily living may have resulted in a change in needs.”

Second, some consumers might engage with treatment during their sessions but become difficult to contact between sessions. If a consumer doesn’t join the session or answer their phone at the scheduled appointment time, simple forgetfulness could be to blame. “I will work with my consumers to set a reminder alarm on their cell phones for our session. It’s helpful to have them set a reminder to go off before the actual time of the session so they are ready at the scheduled time,” Kristen suggests. “I also ask my consumers to answer the phone even if they aren’t able to meet at that time; that way we don’t have a lapse in communication.”

Finally, other consumers may be difficult to engage during their session or express a desire to end the session early. Kristen explains what she does to work with these kinds of consumers during virtual sessions:

“For my consumers who tend to process information internally (as opposed to those who process by talking out loud), there can be a discomfort when too much emphasis is placed on dialogue. For these consumers, I love doing timelines and/or visuals to guide discussion and understand past history. The option for consumers to share photographs or special objects offers additional ways to engage. For my consumers who communicate via resistance, I use motivational interviewing and rapport-building techniques while also setting firm boundaries. Humor and sarcasm, if appropriate, can be helpful to change the mood and tone of the session. If there is insistence on ending the session, I provide the option of taking a five-minute break. Regardless of how much time they give to the session, I make note of the small successes, and I strive to end on a positive note. And for my consumers who struggle to focus, I make these sessions as active and engaging as I can over the phone. For those with video access and their own deck of cards, I may supplement dialogue or skill-building with a card game. It can also be helpful to add some type of physical activity, such as every time the consumer engages in an undesired behavior, they will then implement a physical activity of their choice. This serves the purpose of bringing attention to the thoughts, feelings or behaviors we are trying to change while also enhancing focus and engagement.”

Best Practices for Adapting to Remote Work

Of course, keeping consumers engaged with treatment is harder if you as the provider are also struggling to stay engaged. Remote work is a new arrangement for many behavioral health professionals, and some might be surprised to find that working from home requires a different type of discipline than working in an office environment. Fortunately, providers can take a few simple precautions to improve their focus and productivity when treating consumers virtually.

It can be tempting when working from home to relax your regular morning routine. Waking up late and working in pajamas sounds nice, but departures from your normal work preparations can instead prime you to be unproductive. “Every day feels like the weekend if I don’t create my own structured work routine at home. I’m trying to make it feel as much like a typical workday as I can so that I keep that mindset,” Kristen says. “This helps me maintain consistency with my own behaviors, which also creates a feeling of familiarity for my consumers.

If possible, it’s also best to work in a different area of the home than where you spend your leisure time. Just as maintaining your normal work routine can help you stay in a working mindset, having separate environments for work and leisure can improve your focus and productivity during working hours. “Setting up an area of my home that I use specifically for work helps me create a conscious separation between work and home. This helps with productivity during the workday and also makes it easier to transition out of ‘work mode’ when my workday is done,” Kristen says.

One more thing to consider is the privacy of your workspace. Anyone else who lives in your home should know when you are working and when it is and isn’t acceptable to disturb you. Setting and adhering to these boundaries is important for the confidentiality of your sessions as well as your productivity, as Kristen explains:

“My family understands the nature of my work, and they are respectful of my need for a confidential space. I make my consumers aware that although I am working from home, their privacy and confidentiality is important to me. I let them know about the measures I have taken in order to provide a secure and safe place to open up, and I ask my consumers to follow suit by finding a space in their homes away from distractions and other people. My hope is for our teletherapy sessions to have the same safe and comfortable atmosphere as when we meet in the office.”

Although teletherapy requires some adjustment on the part of care providers, it is an extremely valuable asset when seeing consumers in person isn’t possible. We encourage behavioral health providers to utilize these tips in their day-to-day work to overcome some of the most common obstacles of telemental health care!

Looking for more tips to help improve your professional skills and behaviors? Take a look at our posts on multitasking and the Imposter Syndrome below!

Stress Can Be Good For You (as in this picture of a woman doing her homework)
Why Multitasking Doesn't Work at Work
Perfectionism and 'Hurry Worry'
Embracing Your Inner Expert: Perfectionism and the Impostor Syndrome in Mental Health

Observing Alcohol Awareness Month with Cummins’ Erin Flick and Virtual IOT

Have you ever wondered how long it takes to form a new habit? While the process varies from person to person, one influential study found that it takes 66 days on average. However, some participants in the experiment were able to learn a new habit in just 18 days. This research suggests that under the right circumstances, people are capable of making long-lasting changes to their behavior in a relatively short amount of time—for better or worse.

Since 1987, the National Council on Alcoholism and Drug Dependence has designated April as Alcohol Awareness Month. This public health program aims to educate Americans about the dangers of alcohol use and alcohol dependence, and it comes at a crucial time this year. With many people stuck at home on account of the COVID-19 crisis, some are turning to alcohol use to pass the time. A quick search of Google Trends shows that online searches for “drinking games” have been on the rise since March, with “quarantine drinking games” and “virtual drinking games” exploding in popularity.

Although moderate alcohol consumption may be safe for some people, periods of increased use can lead to the development of dependence and other issues. And since people are capable of ingraining new behaviors over the span of just a few weeks, the ongoing lockdown provides ample time for someone’s drinking habits to change. For these reasons, it’s important that we keep track of our alcohol consumption, recognize the signs of problem use, and know where to get help if we need it.

For more information about identifying and treating alcohol use disorder, we spoke with Erin Flick, a Substance Use Disorder Specialist and Team Lead based out of our Greencastle office. In this post, Erin shares some of the most common symptoms of alcohol dependence, and she also explains how Cummins Behavioral Health has begun providing virtual outpatient services to help people with substance use disorder during the current pandemic.

Erin Flick on Identifying Problematic Substance Use

Erin Flick, MSW, LCSW, LCAC, Substance Use Disorder Specialist and Team Lead at Cummins Behavioral Health
Erin Flick, MSW, LCSW, LCAC, Substance Use Disorder Specialist and Team Lead at Cummins Behavioral Health

Substance use disorder (or SUD) can cause immeasurable harm to a person’s life, but one big challenge of prevention is that SUD can sometimes be difficult to detect. Although there are many signs that someone may be chemically dependent on a substance, they can be subtle and tough to spot in ourselves or others, especially early in the progression of the disorder. Knowing the signs of problematic use can help us identify and seek help for substance use disorder sooner rather than later.

“Problematic substance use may look different for everybody, but if you’re questioning whether someone is developing a problem, one thing to reflect on is what their ‘normal’ has been and if there have been changes to their normal,” Erin says. She also encourages you to ask yourself the following questions; if the answer to one or more is “yes,” then it’s possible that the person is suffering from substance use disorder:

“Does the person have a change in friends, or if they’re normally very social, are you not seeing or hearing from them as much? Has their sleep hygiene changed? For example, are they staying up all night, or do they have their days and nights mixed up? How is their energy level? Have they usually been laid-back, easy-going and task-oriented, and now they appear more energetic and focused on things that they weren’t focused on before? If the person would come home and have one beer at dinner, for instance, are they drinking a little bit more? Are they continuing throughout the evening? If they have responsibilities such as work or school, have they been neglecting those responsibilities?”

In addition to these signs, the Mayo Clinic lists the following behaviors as possible symptoms of substance use disorder:

  • Having intense cravings for the substance that block out other thoughts
  • Needing more of the substance to get the same effect as before
  • Experiencing withdrawal symptoms when you stop using the substance
  • Spending money on the substance even when you can’t afford it
  • Continuing to use the substance even though you know it’s causing negative consequences in your life
  • Doing things to obtain the substance that you normally wouldn’t do, such as stealing

 Introducing Virtual IOT for Treatment of Substance Use Disorder

If you or someone you know develops a problem with alcohol or other substances, the ongoing State lockdown isn’t a good reason to put off seeking treatment. Early intervention has been proven effective at addressing risky substance use behaviors before a disorder can develop, so it’s crucial to get help as soon as you notice a problem. Fortunately, the option of virtual treatment makes this possible even during the COVID-19 pandemic.

We’ve spoken previously about how Cummins BHS has adopted telehealth technologies to care for our consumers, and this extends to our services for substance use disorder. Intensive Outpatient Treatment, or IOT, is one of our most popular services for treatment of substance use disorder, and it’s now being provided virtually in Montgomery and Putnam counties. “We utilize a platform called RingCentral Meetings,” Erin says. “Group members can log in through their phone or their computer, and we engage the group with the same rituals and format as we would if we were sitting in a circle together.”

Just like with any telehealth service, it can take some time for providers and group members to adjust to the dynamics of virtual IOT meetings. However, virtual sessions allow participants to continue receiving care from the safety and comfort of their own homes, and they can even provide some unanticipated benefits to the therapeutic process. Erin explains,

“There’s been a lot of positive feedback in regards to consumer engagement. Those clients that previously had barriers to get to the facility for Group seem to be the ones that are ready to go every morning virtual Group is facilitated, so it’s been encouraging to see that commitment level. And for the providers, it’s nice to get to see some of their consumers’ home environments. We hear about them and can only imagine when we’re sitting in Group, but with video chat, we have an inside look into whatever their environment is. For example, their family members or children might pop in as they’re walking through the house, so it’s a nice way to get a visual of those things.”

As Indiana’s coronavirus lockdown continues, we encourage our consumers to make use of all our virtual care services for their behavioral health needs. You can read more about how our telehealth sessions work in this blog post.

If you believe you may need treatment for a substance use problem during this time, virtual services may be an option for you. Speak with your provider if you’re already a Cummins consumer, or call (888) 714-1927 Ext. 1501 to schedule a new consumer appointment.

Explaining Telehealth: How It Works and What to Expect During a Virtual Behavioral Health Session

Telehealth, the practice of conducting health care via telephone, video or other means of communication technology, has been slowly growing in popularity and practicality over the past several decades. However, the ongoing COVID-19 pandemic has led to a rapid adoption of telehealth services across the mental health industry. Organizations like Cummins Behavioral Health have a responsibility to continue providing life-saving mental health care for our consumers, and this is where telehealth can help.

Although telehealth for behavioral health care is a relatively new frontier, research has shown that virtual sessions with a behavioral health professional can be just as effective as face-to-face meetings. For example, one 2013 research review found that telemental health care is effective for diagnosis and treatment across many populations and appears to be comparable to in-person care. Some care recipients might even prefer telehealth sessions to in-office visits, as a 2012 survey found that 42% of teens and 33% of adults feel more comfortable sharing personal information online than in person.

Nevertheless, most people have very little experience using telehealth services, so the process might seem somewhat confusing or intimidating. Those who aren’t well versed in the latest communication technologies might feel especially uncertain about navigating a phone or video conference with their care provider. Fortunately, most of these technologies are very easy to operate using some basic instructions.

To make the transition to telehealth services as seamless as possible for our consumers, we spoke with IT Director Kevin Dykes about the technologies Cummins is using to provide virtual care during the current health crisis. In this blog post, we explain exactly how to use each of our videoconferencing tools and what you should do to prepare for a virtual session with your care provider.

How to Connect to a Virtual Session with Cummins BHS

Kevin Dykes, IT Director and Information Security Officer at Cummins BHS
Kevin Dykes, IT Director and Information Security Officer at Cummins Behavioral Health

Until the Centers for Disease Control (CDC) and Indiana state government relax their guidelines on social distancing, the vast majority of appointments at Cummins BHS will be conducted virtually, which includes individual therapy and counseling, group therapy and counseling, skills training, employment skills training, peer recovery sessions and medical appointments. This means that most consumers will be asked to call into a phone or video appointment instead of meeting at their local Cummins office.

Before you attend your first virtual session, your care provider will contact you to determine which electronic devices you have access to. “You’ll have the option to use your smartphone, a tablet or a computer, and your care provider will have a discussion with you about the audio/video requirements,” Kevin explains. “In the event that you don’t have video capabilities, then your provider can resort to a basic phone call.”

Your provider will choose the best option for conducting the virtual session based on the resources available to you. Video calls require that you have a device with a camera and microphone, access to the Internet, and a personal email address. However, you might still be able to join a video call if you lack one or more of these items. “There are several meeting options available and more than one way to connect to your meeting. For instance, if you don’t know your email address or you don’t have access to the email address, there are ways to work around that,” Kevin says.

In most cases, your provider will ask to connect with you using one of three possible videoconferencing technologies. Once you know which technology you’ll be using, simply follow the steps below to connect to your virtual session.

If you are meeting via RingCentral:

  1. Your provider will send you an email containing a link to the video meeting. On the appropriate date and time, you can join the meeting by clicking the link on any device that is connected to the Internet. Alternatively, your provider could send the link via text message, which you can follow to the meeting in the same way. If you do not have Internet access, you can instead call into the meeting via phone by dialing the phone number included in the email or text message.
  2. If you would like, you can also download the RingCentral Meetings app on your smartphone, tablet or computer. If you do this, clicking the link your provider sent will open the meeting in the RingCentral Meetings app.
  3. If you don’t have an email address or don’t have access to your account, your provider will call you and give you a ten-digit meeting ID. On the appropriate date and time, you can join the meeting by visiting, clicking on “Join a meeting” at the top right of the screen, and entering the meeting ID when prompted.
  4. You may be asked to enter your name before you can join the meeting. Once you’ve done so, you’ll be connected to the meeting session.
  5. If you see a pop-up window on your device asking for permission to access your camera and/or microphone, select “yes.”

If you are meeting via Zoom:

  1. Your provider will send you an email containing a link to the video meeting. On the appropriate date and time, you can join the meeting by clicking the link on any device that is connected to the Internet. Alternatively, your provider could send the link via text message, which you can follow to the meeting in the same way.
  2. If you don’t have an email address or don’t have access to your account, your provider will call you and give you a nine-digit meeting ID. On the appropriate date and time, you can join the meeting by visiting, clicking on “Join a meeting” at the top right of the screen, and entering the meeting ID when prompted.
  3. You may be asked to enter your name before you can join the meeting. Once you’ve done so, you’ll be connected to the meeting session.
  4. If you see a pop-up window on your device asking for permission to access your camera and/or microphone, select “yes.”

If you are meeting via

  1. Your provider will send you an email containing a link to the video meeting. On the appropriate date and time, you can join the meeting by clicking the link on any device that is connected to the Internet. Alternatively, your provider could send the link via text message, which you can follow to the meeting in the same way.
  2. The link will take you to your provider’s “virtual waiting room,” where you will be asked to enter your name. Once you’ve done so, you’ll need to wait until your provider initiates the meeting.
  3. If you see a pop-up window on your device asking for permission to access your camera and/or microphone, select “yes.”

Preparing for a Successful Telehealth Session

Knowing how to join a telehealth session isn’t the only thing that determines the success of virtual care, however. Since you won’t be meeting in the controlled environment of your care provider’s office, there are more opportunities for distractions and problems that could reduce the quality of your session. To prevent this from happening, you should take the following steps to prepare for your meeting:

  • Find a private space. It’s important that you have privacy to speak openly with your care provider. If other people are in the home during your meeting, inform them that you are attending a telehealth session and ask not to be interrupted during it.
  • Keep extraneous noise to a minimum. Noise from other people and activities in the home can be very distracting during your session. Ask others to stay as quiet as possible while you are meeting, or consider wearing headphones to help drown out other sounds.
  • Try to ensure a stable connection if possible. Poor connection to the telehealth session could make it difficult for you and your provider to see or hear each other, or it could result in the call dropping. Use the fastest and most reliable Internet connection available to you, whether that’s a wired connection, WiFi or your mobile phone data network.
  • Minimize distractions. Do everything possible to eliminate any potential distractions prior to your session. For example, you should refrain from multitasking during the session, which includes eating or drinking any food items. Keep pets contained in another room if possible, and provide children with an activity to do during the session if they will not be involved in the session. Take care of personal needs such as eating and using the restroom prior to the start of the session. Finally, silence all electronic devices and alerts for the duration of the meeting.
  • Gather supplies before the session if possible. Again, your meeting will go most smoothly if all interruptions can be avoided. Check with your provider to see if you’ll need any supplies for activities during your session, and gather them together before your session begins.
  • Use a computer or tablet with video capabilities if possible. In order for you and your provider to see each other’s facial expressions, share files, and share screens (to review handouts/resources, complete activities, etc.), we recommend that you use a webcam and a computer or tablet so that you have the largest possible screen. It’s also best to place the device on a hard surface rather than hold it, as this reduces movement and noise during the session.
  • Maintain a professional relationship and boundaries. Even though you won’t be meeting at your care provider’s office, you should still adhere to all the normal guidelines of the provider-consumer relationship. Dress and behave just as you would if you were coming into the office for your session.

Although telehealth services might take some time to get used to, they allow organizations like Cummins Behavioral Health to continue providing crucial behavioral health care while keeping our employees and consumers safe during this health crisis. We encourage you to refer back to this post if you forget what happens next in the virtual care process, or consult your care provider if you need further clarification regarding specific details.

For more information about safeguarding your physical and mental health during the COVID-19 crisis, we recommend reading the articles below!

Cummins Behavioral Health’s Response to COVID-19
COVID-19 and the Diathesis-Stress Model: How to Relieve Stress under Extraordinary Circumstances

COVID-19 and the Diathesis-Stress Model: How to Relieve Stress under Extraordinary Circumstances

Everyone experiences periods of increased stress in their life. These may be mild and recurrent, such as the stress involved in working or raising children, or they may be more severe and unique, like the stress of losing a job or getting a divorce. When we encounter a stressful situation, we can usually get through it without any lasting repercussions. However, extreme or prolonged periods of distress can sometimes have negative effects on our mental well-being.

The diathesis-stress model, which is sometimes also called the stress-diathesis model, is a psychological framework for understanding how stress affects our mental health. According to this model, every person has a certain amount of vulnerability toward depression, anxiety, and other mental health problems and conditions. Although some people do not struggle with these issues under normal circumstances, extreme distress can sometimes cause symptoms to develop where none existed before. And for people who do struggle with a mental health condition under normal circumstances, additional distress can worsen their symptoms and make management of their condition more difficult.

As the public health crisis created by the COVID-19 disease continues, it’s important that everyone be prepared for the ways this additional stress might affect their health. Even individuals with no preexisting behavioral health conditions may find themselves feeling more worried, anxious or depressed over the coming weeks. Fortunately, we can all lessen the negative effects of this particular stressor by taking precautions to boost our emotional resilience.

To learn more about what to expect and how to manage behavioral health issues during this difficult time, we spoke with Margot Everitt, one of our Team Leads for school-based services in Marion County. Below, Margot explains how a person’s health might be impacted and what they can do to relieve stress during this or any other extraordinary situation.

Explaining the Mental Health Risks Posed by COVID-19

Margot Everitt, LMFT, School-Based Team Lead at Cummins Behavioral Health Systems
As a Team Lead for school-based services, Margot Everitt, LMFT, supervises therapists and life skills specialists who work with children and teens in the Indianapolis school system.

As stated above, most people should expect to experience some amount of increased distress due to the ongoing situation with coronavirus disease. Individuals who have an existing mood or anxiety disorder are the most likely to experience worsened symptoms as a result of this added stress. While symptoms of increased distress will vary from person to person, Margot anticipates that they will follow two main trends.

First, a person might experience reduced well-being right now, as we are living through the crisis day-to-day. “When there is a stressful situation like what we’re going through right now, if you already have anxiety, for instance, you’ll likely feel increased symptoms,” Margot says. “When people are worried about getting their basic needs met, that’s when we see things like depression and anxiety come into play.”

These effects could be more pronounced if a person’s employment status has changed, if their normal daily routines have been greatly interrupted, or if they spend a lot of time following the situation’s development. “You could see increased symptoms if you’ve lost a job, if you’re watching the news, or if you’re not able to do things that help you relieve that stress,” Margot says.

Second, a person might also experience increased distress when they must transition back to normal life at the end of this crisis. For some people, this stress could be the result of employment changes and financial difficulties. For others, it could occur due to the strain of returning to old habits and routines, as Margot explains:

“For example, some kids have a lot of anxiety and struggle with going to school because of that anxiety. My concern is that this whole situation will make the transition back to school much more difficult. Right now, they’re getting used to being in their homes and in their ‘cocoon,’ so I think they’re going to have a harder time transitioning back to school. In the same way, getting back into the workforce may be difficult for adults who aren’t working or have been laid off.”

What You Can Do to Guard Against Distress

Once we understand how additional distress could impact our mental health, it’s important that we take measures to counteract these negative effects. One of the best ways to manage distress is to continue normal wellness behaviors like exercising frequently, eating nutritious food and maintaining a regular sleep schedule. These behaviors have been proven to boost resilience and improve mental health, so continuing them during times of crisis is critical.

Since many of us are currently spending a great deal of time at home, we might find it difficult to continue our regular wellness routines. However, we can work within existing constraints to continue our wellness behaviors to the best of our abilities, as Margot explains:

“For sleep, you should keep a consistent sleep schedule and have a good bedtime routine. Do something that relaxes you before going to bed, and get up at the same time you always get up. If you’re staying up all night and sleeping late into the day, that’s going to change your body chemistry, and then how are you going to function when you have to go back to your regular hours? For exercise, any kind of movement is beneficial, and there are things you can do to modify your normal exercise routine. Take a walk, or if you live in a neighborhood where you don’t feel safe walking outside, then walk around your house. Get a milk jug and lift it as a weight, or do jumping jacks. For nutrition, practice healthy eating and try not to snack all day. Have dedicated times for eating breakfast, lunch and dinner. You should do all the same things you were doing before and figure out how to modify those behaviors for the present circumstances.”

In addition to these wellness behaviors, Margot emphasizes the importance of building structure into our day even if we aren’t leaving the house for school or work. “It’s very important for kids and even adults to create structure, although it’s going to look different than normal. They need to get up, take a shower, eat breakfast—whatever their routine is—even if they don’t leave the house. I think people will feel a lot better if they keep a structured day,” she says.

Finally, it’s a good idea to limit your exposure to anxiety-inducing information and news about the crisis. While it’s important to stay informed of new developments, spending excessive amounts of time tracking the situation will likely increase your level of distress. “I think people have to be really careful,” Margot explains. “There’s so much information out there that’s just going to increase anxiety and paranoia. Right now, I don’t watch the news unless it’s something like Good Morning America, and when I get on social media, if I start seeing too many things about the coronavirus, I get off. Some people might need to limit or eliminate these things if they’re causing too much stress.”

In times of heightened anxiety and distress, we must also be sure to continue regular appointments with behavioral health professionals. Although Cummins BHS is limiting face-to-face sessions during the COVID-19 crisis, our providers are still conducting sessions via telephone and video conference. Call us at (888) 714-1927 Ext. 1500 if you’d like to schedule an appointment, or dial extension 1501 if you are experiencing a mental health crisis and need to speak with someone immediately.

Looking for more advice about coping with stress and anxiety? Here are some other posts we recommend!

Stress Can Be Good For You (as in this picture of a woman doing her homework)
Remember This Next Time You’re Feeling Stressed
Yoga, meditation
Calm Down Quick With this Simple Trick: Extended Exhale

Cummins Behavioral Health’s Response to COVID-19

The rapid worldwide spread of the COVID-19 disease, also known as the coronavirus disease, has created a public health crisis the likes of which have not been seen for many years. Cummins Behavioral Health is closely monitoring developments in this unfolding situation, and the safety and well-being of our consumers and employees continues to be of utmost importance to us. First and foremost, if you are experiencing a mental health crisis during this challenging time, we encourage you to call our 24-hour emergency phone line at (888) 714-1927 Ext 1501.

We understand this crisis is impacting everyone’s daily life in various ways. We are dedicated to ensuring your safety while limiting the impact this health event has on the services we provide. We will continue to follow guidelines from the Centers for Disease Control (CDC) as well as federal, state and local governments to help prevent the spread of the COVID-19 disease in our community. We are keenly focused on maintaining a safe environment for our employees and consumers while continuing to provide services.

We have robust integrated behavioral health processes in place, and they are managed by a dedicated team of professionals committed to ensuring your well-being and keeping our operations running as smoothly as possible during these trying times. As such, we have put the following response plan into action, effective immediately:

New Policies to Prevent the Spread of COVID-19:

  1. Anyone exhibiting symptoms of COVID-19 and/or acute respiratory illness should not come in for therapy or counseling sessions. This policy applies to both consumers and members of our staff. Click here to reference the CDC’s official list of COVID-19 symptoms. Individuals who are ill and in need of hospitalization may be permitted entrance into our facilities in some circumstances.
  2. Until further notice, therapy sessions and other services will be conducted via telephone or video conference whenever possible. Individuals who are not ill and who have an imperative need for face-to-face care will be permitted into our facilities on a case-by-case basis. Your care provider will inform you how your sessions will be handled moving forward.
  3. Additionally, we have temporarily suspended our Open Access for initial assessments. Please call our offices at (888) 714-1927 Ext 1500 to schedule an initial appointment. 
  4. All consumers and staff should follow the hygiene protocols laid out by the CDC both inside and outside Cummins’ facilities. These include frequently washing your hands with soap and water for at least 20 seconds, using hand sanitizer with at least 60% alcohol when soap and water isn’t available, coughing and sneezing into a tissue or the inside of your elbow instead of your hand, and refraining from touching your face with unclean hands. We invite you to visit the CDC’s webpages on handwashing and coughing and sneezing etiquette for more information.
  5. All individuals should practice social distancing to prevent the spread of illness. This means staying home when possible and only leaving the home when absolutely necessary, staying six or more feet away from other people, and reducing or eliminating large group gatherings.

We will continue to monitor this fluid situation and modify our response as necessary to ensure essential services to our consumers and our community. Check back with this page for further updates and changes to our policies as more information becomes available. We also recommend reviewing this COVID-19 Quick Facts Sheet prepared by the CDC.

For decades, Cummins has demonstrated unwavering support to our consumers. In dealing with the present circumstances, we will continue to use every effort to deliver essential services to all our clients to the utmost of our ability. On behalf of everyone here at Cummins, we appreciate your cooperation and support as we forge a path ahead during this uncertain time.

Observing Self-Harm Awareness Month: Cummins CCO Robb Enlow on 13 Myths and Misconceptions of Suicide

“Suicide is a solitary event, and yet it often has far-reaching repercussions for many others. It is rather like throwing a stone into a pond; the ripples spread and spread.” — Alison Wertheimer

Although most of us would prefer otherwise, everyone feels negative emotions in life. Feelings like sorrow, grief, guilt, shame, hopelessness and worthlessness can be extremely difficult to deal with and taxing on our mental well-being. Often we find the strength to hold on until the feeling passes, but sometimes, for one reason or another, we might feel the urge to phyically harm ourselves in order to escape intense emotional pain. In the most extreme cases, we might consider ending our own life to make the pain go away.

Suicide is a major public health concern throughout much of the world. It affects all races and genders, and in the United States, it is the 10th leading cause of death. In addition to deaths by suicide, the American Foundation for Suicide Prevention estimates that there were 1.4 million suicide attempts in 2018. However, suicide remains highly stigmatized in America and elsewhere, and it is often misunderstood as a result.

March is internationally recognized as Self-Harm Awareness Month (or Self-Injury Awareness Month), and in observance, Cummins Behavioral Health hopes to improve understanding and erode the taboo surrounding suicide, the most drastic of all forms of self-injury. Persistent myths and fallacies about suicide not only isolate those who have contemplated or attempted it, but they can also prevent people from receiving help during a time of emotional crisis.

To get to the bottom of what is and isn’t true about suicide and suicidal behavior, we spoke with Robb Enlow, Chief Clinical Officer at Cummins BHS. Robb provided us with an evidence-based curriculum he assembled that explains and debunks 13 of the most common fallacies about suicide and those who struggle with the urge to take their own lives.

13 Common Fallacies about Suicide, Explained

Robb Enlow, LCSW, Chief Clinical Officer at Cummins BHS

Fallacy #1: Most suicides are caused by a single traumatic event.

Too often, people assume that the decision to take one’s life is made following a single highly upsetting event. As a result, they might believe that suicide happens so quickly that it cannot be prevented. In reality, a sudden traumatic event is unlikely to be the only cause of suicidal ideation. “More typically, these events are one of other contributing events and feelings which have occurred over time. The stressful event and the person’s reaction to that event should be viewed as invitations to help,” Robb’s curriculum states.

Fallacy #2: Most suicides occur with little or no warning.

A similar misconception is that people decide to end their lives in secret, without giving any indication that they’re thinking about doing so. As with the previous fallacy, this belief can lead to a sense of futility toward suicide prevention efforts. However, most people who have suicidal thoughts communicate their feelings and struggles with others before actually attempting suicide. According to Robb’s curriculum, “These invitations for others to offer help come in the form of direct statements, physical signs, emotional reactions, or behavioral cues indicating the person may be considering suicide as a solution to their problems.”

Fallacy #3: Youth suicides occur with little or no warning.

Teenagers and adolescents are often thought to be flighty and emotionally volatile, which can make caretakers feel even more hopeless about the possibility of preventing suicidal behavior. But just as with adults, young people usually communicate their distress in one form or another prior to attempting suicide. “Although youth may appear to be constantly changing, change is seldom made without purpose or thought,” the curriculum points out. “Not all youth act with haste. Additionally, young persons who do act in haste (impulse) often have a history of other risky behaviors such as substance abuse, reckless driving or unprotected sex.”

Fallacy #4: You shouldn’t talk about suicide with someone who you think might be at risk.

Some people still believe the myth that talking about suicide can “plant” the idea in a person’s head. As a result, they might think it best to avoid the topic altogether when they believe someone is at risk. On the contrary, serious talk about suicide reduces risk rather than creating or increasing it. As the curriculum explains, “Open talk and genuine concern about someone’s thoughts of suicide are a source of relief for them and are often the key elements in preventing the immediate danger of suicide. Avoidance leaves the person at risk, feeling more alone and perhaps too anxious to risk asking someone else to help.”


Fallacy #5: People who talk about suicide won’t do it.

On the other hand, some people may believe that anyone who talks about suicide is not seriously considering it. They might think the person is only seeking attention or pity and therefore choose not to offer any help. As we mentioned above, people who attempt suicide usually talk about their intentions before they act, so any talk of suicide should be taken seriously. “Most people who die by suicide talk about it in some way before they act. Not taking this talk seriously may be a contributing cause in many deaths by suicide,” the curriculum states.

Fallacy #6: A nonfatal outcome means it was only an attention-getting behavior.

In the same way people may dismiss talk about suicide as nothing serious, they might also believe that a nonfatal attempt proves the person doesn’t really intend to go through with it. With this in mind, they might ignore the person’s behavior so as not to reward or encourage it. This belief is false, as nonfatal suicide behaviors are often a desperate invitation for help. “If help is not offered, the person may conclude that help will never come and others not taking them seriously could be another reason for dying,” the curriculum states.

Fallacy #7: Suicidal people want to die.

Perhaps one of the biggest misconceptions about suicidal behavior is that the person who is engaging in it wants to die. In actuality, most people who are suicidal are deeply conflicted and unsure about dying, often up to the very moment of acting. It’s very important that others understand this so they won’t be discouraged from attempting to help. “Most people are looking for help to avoid suicide even if they aren’t immediately aware that they want help. The vast majority of people who are suicidal at some time in their life find a way to continue living,” the curriculum explains.

Fallacy #8: All people who take their own lives are mentally ill.

It’s true that there is a correlation between suicidal behavior and mental illness. However, this doesn’t mean that all suicidal people are mentally ill or that treating mental illness eliminates the risk of suicidal behavior. Rather, mental illness and suicide risk must be managed concurrently in order to give the person the best chance of recovery. In the curriculum’s words, “Not all people who die by suicide are mentally ill, nor are all who are mentally ill likely to die by suicide. Risk behaviors are treated parallel to mental illness.”

sarah crying

Fallacy #9: Once a person attempts suicide, they won’t do it again.

Yet another false belief about suicide is that if a person attempts to take their life and fails, then they won’t try again. Rather than alerting friends and family to the need for intervention, this belief may convince them that the risk of suicide has ended with the unsuccessful attempt. The truth is that many people who attempt suicide will do so again in the future. According to the curriculum, “The rate of suicide for those who have attempted before is 40 times higher than that of the general population. Prior suicide behavior is a major risk factor.”

Fallacy #10: When a person feels better, the danger is over.

When someone who has been struggling with suicidal thoughts and behaviors appears to suddenly improve, many people assume this means the danger of suicide has passed. While this may be true in some cases, in others it may signify that the person has made up their mind to take their life. Therefore, efforts to mitigate risk should continue. “Feeling better can have different meanings: a decision for life, or the person has made the decision to die and is no longer in emotional conflict. Continued discussion is needed,” the curriculum cautions.

Fallacy #11: Most people who kill themselves just couldn’t make it in society.

One extremely harmful myth about suicide is that it’s inevitable for some people. Some may believe that suicidal individuals are so dysfunctional that they can never succeed in the world, so it’s better to just let them end their lives. This line of thinking is incorrect, as most people who think about suicide never act on the idea, and most only seriously consider suicide once in their lives. “Suicide is a choice anyone can make, although almost no one wants to be suicidal. Your efforts to help may be enough to support a person through a difficult and dangerous period of their life,” the curriculum explains.

Fallacy #12: People who kill themselves are taking the easy way out.

In a similar vein as the previous fallacy, some people believe that those who contemplate, attempt or complete suicide are morally weak. They may think that suicidal individuals do not deserve help, or worse yet, that society would be better off without them. This view ignores the tremendous emotional burden of suicidal thoughts, and it also reduces the chance that a suicidal person will recover. “Most people at risk are desperately looking for another way out of their situation. Labeling people at risk in such a negative way serves only to make it harder for them and for other persons at risk to reach out for support,” the curriculum states.

Fallacy #13: Suicide is an individual choice.

Finally, even those who have the best intentions and who would like to help a suicidal person may believe it isn’t their place to do so. They might think that if a person says they want to die, it isn’t right to intervene. However, it’s important to remember that suicide is rarely a person’s preferred choice, and it is therefore not disrespectful to exercise prevention measures. “The decision for suicide may be made in the midst of many turbulent feelings and is seldom the result of informed decision-making about all the possibilities,” the curriculum states.


In order to reduce stigma surrounding suicide and lower rates of suicidal behavior, it’s crucial that everyone understands what is and isn’t true about suicide and individuals who consider or attempt it. In honor of Self-Harm Awareness Month, we encourage you to spread awareness of these suicide myths and misconceptions and open a dialogue with anyone you know who might be struggling with self-injury or suicidal thoughts.

Here at Cummins Behavioral Health, our therapists and counselors use a model known as “Assessing and Managing Suicide Risk” (AMSR) to detect and intervene on suicidal tendencies. If you or someone you know struggles with self-injury or suicidal ideation, feel free to call us at (888) 714-1927 to discuss treatment options.

For more information about difficult behavioral health situations you may face and how you can work to overcome them, here are a few more posts we recommend.

Managing Dual Diagnosis: Cummins’ Tracy Waible on How to Identify and Treat Substance Use with Co-Occurring Disorders
Identifying Toxic Relationships: Dr. Armen Sarkissian Explains How to Escape the “Drama Triangle” Trap

Trauma-Informed Care: What It Means and How It Can Be Implemented in Behavioral Health

“Trauma leaves ‘fingerprints’ on the victim. These don’t fade when the bruises do.” — Dr. Ellen Taliaferro, physician and author specializing in domestic violence and abuse

Violent events—whether they occur on purpose or by accident, and whether they are physically or emotionally violent—leave a mark on a person’s psyche. Long after an event has passed, its memory can cause psychological suffering for those who experienced it. In some cases, this prolonged suffering may be diagnosed as post-traumatic stress disorder, but the event and its emotional consequences are also referred to more generally as trauma.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), trauma “results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” Statistics from SAMHSA show that 61% of men and 51% of women are exposed to a traumatic event sometime in their lives, and 90% of clients in public behavioral health care settings have experienced trauma.

We’ve previously explained how interventions like yoga can help to reduce symptoms of post-traumatic stress, but most of the time, trauma is so deep-seated that it must be addressed by professional therapy or counseling. However, it’s crucial that behavioral health care is delivered in a way that’s attentive to the needs of trauma victims. The last thing that’s wanted is for treatment to trigger residual feelings of stress and anxiety, which is why all care must be trauma-informed.

Trauma-informed care is a framework for treatment that helps clients feel safe, respected and in control while minimizing any risk of re-traumatization. Here at Cummins Behavioral Health, we strive to integrate the principles of trauma-informed care into every interaction between care providers and consumers. We spoke with Rebecca Bradford, Team Lead at our Marion County outpatient office, to learn more about trauma-informed care and how it can be effectively implemented in behavioral health care.

The Six Principles of Trauma-Informed Care, Explained

Rebecca Bradford, LCSW, Marion County Team Lead at Cummins BHS
As Team Lead at Cummins' Marion County outpatient office, Rebecca Bradford, LCSW, supervises therapists and clinicians as well as peer service providers.

As mentioned above, trauma affects more than half of all adults in the U.S., and the percentages are even higher among people who seek out behavioral health services. Interestingly enough, a higher than average number of behavioral health workers may have also experienced some form of trauma in the past. As a result, a trauma-informed approach to care is important for the well-being of consumers as well as employees within an organization.

“Trauma-informed care is important because there are so many people who have experienced trauma,” Rebecca says. “Whether they have a diagnosable condition like PTSD or not, it is likely that at some point in their life, a large majority of the population we serve has experienced some sort of trauma in their life. It even affects a lot of our providers, because we know that people sometimes go into the helping fields because they’ve experienced things in their own life that make them want to help others.”

But what does a trauma-informed approach to care mean, exactly? According to SAMHSA, trauma-informed care is treatment that adheres to six guiding principles:

  1. Safety: throughout the organization, both staff and the people they serve feel physically and psychologically safe. As Rebecca explains, this is one of the first things that a person who has experienced trauma considers when entering a treatment environment. “If I’m talking to someone who has trauma, their safety has likely been threatened or taken away from them at some point in their life, so that’s going to keep them guarded. We need to make sure the physical space is presented as safe as well as the emotional space, which is often done through rapport-building with consumers,” she says.
  2. Trustworthiness and transparency: organizational operations are conducted with transparency in order to build trust among staff, consumers, and consumers’ family members. This can be achieved with consumers through open communication about everything that happens during treatment. “We use collaborative documentation so consumers know what’s being written about them and what the provider is documenting,” Rebecca says. “Being transparent about the parameters of the therapeutic relationship is very important, as well, and those boundaries get established up-front.”
  3. Peer support: consumers have access to peer recovery specialists who have experienced trauma in their own lives and can provide additional emotional support. Due to their unique position in the organization, peer specialists can often engage with consumers in ways that might be inappropriate for a therapist or counselor. “With trauma, people often feel isolated, so sometimes they feel more comfortable opening up to somebody that has had that experience versus a therapist who may not disclose, even if they have had that experience, just to keep those therapeutic boundaries,” Rebecca explains.
  4. Collaboration and mutuality: consumers act as partners with staff in their own treatment, and the balance of power remains equal between consumer and provider as well as among staff. According to Rebecca, one part of collaboration means that consumers take equal responsibility for their recovery. “A huge part of treatment is that we’re always giving it back to the consumer and not just doing things for them. We teach them how to do things themselves, or we do it with them if they can’t do it themselves just yet,” she says.
  5. Empowerment, voice and choice: consumers are encouraged to take control of their treatment and freely express their concerns and desires. Care providers are facilitators of recovery rather than controllers of recovery, and they strive to support consumers in shared goal-setting and decision-making. “We let the consumer know that they can control the pace of treatment. That’s a big part of Empowerment as well as Safety and Collaboration,” Rebecca says.
  6. Cultural, historical and gender issues: the organization ignores cultural and gender stereotypes and is responsive to the racial, ethnic, cultural and gender-specific needs of consumers. At Cummins, this is partially achieved through the Cultural Competency Committee, which researches and disseminates best practices for treating people from diverse populations. “It’s a matter of continuing to educate our providers on diversity and gender issues and making sure that we’re not imposing our own belief systems on any other person,” Rebecca explains.

Putting Trauma-Informed Care into Practice


Once the core principles of trauma-informed care are understood, the real challenge lies in implementing these principles throughout the organization. In its guidelines for trauma-informed care, SAMHSA lists ten domains for implementation: governance and leadership; policy; physical environment; engagement and involvement; cross-sector collaboration; screening, assessment and treatment services; training and workforce development; progress monitoring and quality assurance; financing; and evaluation.

In Rebecca’s experience, workforce training is among the most crucial of these domains. In order for trauma-informed care to truly make a difference, its principles must be upheld at every point of consumer contact within the organization. “From that first person a consumer meets when scheduling an appointment all the way up to the CEO, everyone should know about these things,” Rebecca says.

Trauma-informed care is typically implemented from the “top” of an organization by means of policy choices, but employees at all levels of the organization should be encouraged to offer input. This helps to ensure that policies remain as current and effective as possible, as Rebecca illustrates:

“At Cummins, leadership is always open to hearing what providers have to say about treatment environments and treatment modalities. For example, my providers were recently discussing needs with the Chief Clinical Officer and identified a book that had some protocols to address poverty, which often goes hand-in-hand with trauma. The Chief Clinical Officer took that input and came back to us two months later, presented his interpretation of the basic ideas, and changed the way we do our onboarding system as a result of reading this book that was suggested by my providers.”

Finally, behavioral health care providers must be careful to avoid common stumbling blocks like burnout and compassion fatigue, which can undermine their ability to administer effective trauma-informed care. For this reason, regular self-care is important for everyone in the organization. “Something we talk about a lot is good supervision and open communication with the provider, with me being able to say, ‘I think you need to take a step back,’ and them also being able to come and say that to me,” Rebecca explains.

Due to the high prevalence of trauma among behavioral health care consumers, it’s imperative that treatment recognizes the challenges faced by trauma survivors and empowers them to improve their own lives. We continually strive for this goal at Cummins Behavioral Health as we work toward our mission of inspiring the hope of recovery in every person we serve.

Looking for more information about recovery from trauma? Here are some other posts we recommend!

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Some say Yoga is simple physical exercises. They’re wrong.

What Does Love Look Like? Raising Awareness of Teen Dating Violence

Intimate relationships can be some of the most rewarding and some of the most challenging things in life. A healthy and loving relationship between romantic partners provides joy, companionship and emotional support for both people involved. Each person can trust the other to have their interests in mind and always try to do what’s best for their partner. However, intimate relationships can have a profoundly negative impact if one or both of the participants do not care what’s best for the other—if they are physically or emotionally violent or abusive.

Unfortunately, everyone runs the risk of getting into a relationship with an abusive partner, especially since abusers may hide their true behavior early in the relationship. However, young people are especially vulnerable since they may lack the experience to detect or identify dating violence. In fact, approximately one in three adolescent girls in the U.S. is the victim of physical, emotional or verbal abuse from a dating partner. Despite this fact, awareness of teen dating violence remains low: some research has found that only 33% of teens who were in an abusive relationship ever told anyone about the abuse, and 81% of parents believe teen dating violence is not an issue or admit they don’t know if it’s an issue.

This is why it’s crucial for young people and adults alike to understand the signs of an abusive relationship. To this end, the federal government has designated February as National Teen Dating Violence Awareness and Prevention Month (TDVAM). All month long, organizations like Break the Cycle and Love is Respect (a project of the National Domestic Violence Hotline) work to inform the public about the risks of dating violence for teens and adolescents.

As February draws to a close, we here at Cummins Behavioral Health wanted to do our part to spread awareness and show support for this important initiative. In honor of TDVAM, this post explores what an abusive relationship looks like, what a healthy relationship looks like, and how to help prevent teen dating violence for yourself, your friends or your children.

How to Tell the Difference Between Love and Abuse

The trouble with violent relationship behavior is that it can build so gradually that it goes unnoticed. Sometimes, the feelings of infatuation that can be common early in a relationship may blind a person to their partner’s abusive behavior until it has escalated to a dangerous level. Knowing the warning signs of dating violence can help us identify an abusive relationship before it has become unmanageable.

In an unhealthy or abusive relationship, one person attempts to control the other. The abuser might pressure their partner into sexual activities or try to control who their partner speaks to and spends time with. The victim in the relationship might feel like they should only spend time with their partner, and they might feel unable or even afraid to tell others about how their partner is treating them. In extreme cases, the abuser may attempt to manipulate the victim, accuse them of wrongdoing, or even dictate what they should and shouldn’t believe.

According to, some common examples of abusive behavior include:

  • Physical violence, such as hitting, choking, kicking, shoving, biting, and force-feeding
  • Emotional and verbal violence, such as putting you down, threatening you, telling you what to do, and accusing you of being unfaithful
  • Digital violence, such as sending threats via text or instant message, stalking you on social media, and logging onto your online accounts without your permission
  • Financial violence, such as taking your paychecks, preventing you from working, controlling your spending, and refusing to pay bills
  • Sexual violence, such as pressuring or forcing you into sexual acts, forcing you to watch pornography, or restricting access to birth control

By contrast, a healthy relationship is founded on mutual respect between both partners. People who are in a healthy relationship are honest with each other about their thoughts, feelings and desires, and they trust their partner to honor their confidentiality. Both people consent to any and all sexual activity, and they communicate their intentions and comfort at every step of a sexual encounter. Finally, a healthy relationship has clear boundaries, with both partners agreeing on how much time they spend together, how quickly or slowly they want to become intimate, and what details of their relationship can be shared with other people online or offline.

What You Can Do to Prevent Teen Dating Violence


Once you know how to identify an abusive relationship, it’s important that you also understand how to help a teen who may be in one. Starting a conversation about dating violence can be difficult, but it’s easier if you know what to say.

If you are a parent or adult authority figure, you should first know that you do have an influence on the decisions young people make. According to the National Domestic Violence Hotline, 25% of people who visit their website say they do so because a teacher referred them to it.

When talking to a teen about their relationship, it’s important that you make your concern for them known, listen to what they tell you, and accept what they say at face value. Any skepticism or accusations on your part could damage the trust in your relationship and discourage them from speaking up again. Similarly, you should never punish or give ultimatums to a teen who is experiencing dating violence, as this will only make it harder for you to help them. You should also avoid speaking negatively about their romantic partner and choose instead to point out that their actions are disrespectful and harmful.

If you are a teen and you suspect one of your friends is in an abusive relationship, the best thing you can do is offer them emotional support. Don’t be afraid to reach out to them if you think they need help, and listen to what they have to tell you. You should try to be respectful of their feelings and decisions while also pointing out the violent behavior you see and explaining that it is unacceptable. Last but not least, focus on building up your friend rather than tearing down their partner, as this might only serve to push them away from you.

Most importantly, whether it’s you, your friend, your child, or a teen you know who is suffering from dating violence, professional help is always available. Behavioral health therapists and counselors can provide advice, support and resources to help anyone get out of a relationship that’s damaging to their well-being.

Here at Cummins BHS, we believe that every person deserves to be treated with love, dignity and respect in all their relationships. We encourage you to spread this message by telling others about teen dating violence and sharing the signs and symptoms of abusive relationships.

And if you believe that professional counseling may be appropriate for yourself or your child, you can call us at (888) 714-1927 to discuss treatment options.

Looking for more information about dating violence, domestic abuse and toxic relationships? These articles may be helpful.

Identifying Toxic Relationships: Dr. Armen Sarkissian Explains How to Escape the “Drama Triangle” Trap
Giving Domestic Violence Survivors a Chance at Independence: Cummins BHS, Sheltering Wings and RealAmerica Announce Haven Homes

How to Change Your Life Using the Stages of Change Model, with Cummins Therapist David Bonney

“To improve is to change; to be perfect is to change often.” — Winston Churchill

At some point in their lives, most people will feel the need to make a change. Maybe they’d like to remove something that’s causing them distress, or perhaps they’d like to add a new behavior that will improve the quality of their life. For example, we’ve previously discussed the benefits that practicing mindfulness, getting enough sleep, eating a balanced diet and exercising regularly can have for a person’s physical and mental health.

However, change can be tricky. Common knowledge suggests that the main obstacle to change is knowing what needs to be done, but this actually isn’t the case. Research shows that the first step in any change is developing an intention to change and believing we have the ability to make that change. Without this internal conviction, any changes to our lives that we might like to make—or think we ought to make—are unlikely to succeed. Once intention is achieved, the change must then be planned out, executed, and maintained into the future.

In fact, the way that successful change happens is very similar regardless of the individual person and the exact thing being changed. Psychologists have found that people move through predictable patterns of thought and behavior as they prepare for and complete a change. This knowledge can be invaluable when we intend to make a change in our life, as it can help us track where we are in the process of change and how to move closer to our goal.

To better explain how someone can make positive changes in their life, we spoke with David Bonney, a therapist and IOT Group Leader at our Marion County office. In this post, David walks us through one of the most popular psychological theories for how people change: the Stages of Change model.

Dividing Change into Its Five Main Parts

David Bonney (MA, LCAC, MAC, CADAC IV, ICOGS), Intensive Outpatient Treatment Group Leader at Cummins Behavioral Health

As part of their daily work, mental health professionals often assist people in changing their behaviors. This is especially true for therapists like David who specialize in substance use disorder. When coaching a client through a big lifestyle change, it’s helpful to know what they’re experiencing at present and how their intentions might shift. The Stages of Change model is a common tool therapists use to map a client’s journey.

“In the area of substance use counseling, the Stages of Change model is one of the predominant models, if not the most predominant model, counselors tend to use across all agencies,” David says. “It’s something that I support as well. I see a lot of validity to it, and it can apply to almost any consumer that we work with.”

The Stages of Change model divides behavior change into five discrete parts that a person progresses through in order. Although the goal of any change is continuous forward progression, a person may regress to a previous stage of the model if they have a relapse in behavior. The stages are as follows:

  1. Pre-contemplation: At this stage, the person has not yet considered changing their behavior. They have either not thought of a change they’d like to make in their life, or they don’t believe that an existing behavior poses a problem. According to David, “In some cases, pre-contemplation is denial. The person’s opinion is, ‘I don’t have a problem, so therefore there’s nothing to work on.’ “
  2. Contemplation: A person at this stage has noticed an opportunity or problem in their life and has started to think about making a change. “With substance use disorder, contemplation is, ‘Yes, maybe there is a problem here. I’m not ready to do anything about it, but I recognize that there’s a problem with my substance use in some way or another,’ “ David says. “They might even go so far as, ‘Maybe I need to stop doing this because it’s a problem.’ “
  3. Preparation: The person has now committed to making a change and is considering how to go about doing so. They may be seeking advice from other people or planning out a course of action. David says, “Preparation is, ‘What am I going to do about this?’ Maybe the person is talking to others or seeking out treatment. It’s the idea that there is a motivation to do something different, no matter what the motivation is.”
  4. Action: As the name implies, a person at this stage is taking measures to make a change. This is typically done by cutting back on harmful behaviors or adopting beneficial ones. “In the case of mental health, the person might be in therapy and actively trying to practice new coping skills and avoid triggers, at whatever level of success. The person is actually making those efforts,” David says.
  5. Maintenance: At the final stage, the person continues to practice their target behaviors and avoids relapsing into old behaviors. This stage is ongoing and does not have a definitive end. “Someone in maintenance is in compliance with whatever they’re supposed to be doing. The idea is to continue doing the things that have gotten them to this point and adapt to their new routines,” David says.

Taking the First Step Toward Change

Stages of Change model
An illustration of the Stages of Change model

Every stage in the Stages of Change model is an integral part of the behavior change process. However, the transition from pre-contemplation to contemplation deserves further discussion. Intention to change is the linchpin that holds the process together, and developing that intention is not always easy. This is especially true when the change is something that we ought to do but not necessarily something that we want to do.

This is a situation that David encounters frequently in substance use counseling. “We have some consumers who have been referred to Intensive Outpatient Therapy (IOT) who say, for whatever reason, ‘I’m not ready yet,’ or ‘I don’t want to go.’ What we might do at that point is meet with them individually to explore their reservations,” he says.

This type of counseling relies on a technique called motivational interviewing. During this process, the therapist or counselor guides the client toward behavior change by exploring their desires and intentions. Rather than telling the client what they should do, the therapist accepts where they are in the change process and helps them clarify any ambivalent feelings they may have. This format prevents therapy from devolving into a power struggle and empowers the client to take responsibility for their own actions.

As David explains, motivational interviewing can help a person decide to make a change by their own choice, on their own terms, and at a speed they’re comfortable with:

“Motivational interviewing is about meeting people where they are with the ultimate goal of building engagement. Sometimes in the pre-contemplation stage, consumers attempt to go in a circle. I try to step outside the circle right away by accepting the consumer for where they are and accepting their line of thinking, whether it’s misguided or not. Then I try to challenge any beliefs they may have that are contrary to what they’re saying. For example, if they say, ‘I want to get off probation,’ I’ll ask how they are going to get off probation. If they then say, ‘Well, I have to quit using,’ I’ll ask what it’s going to take for them to quit using. Then they might say, ‘I’m not going to quit using because there’s nothing wrong with what I’m doing, but I want to get off probation.’ In that case, I’ll try to point out the conflict in their thinking, but I’ll allow them to draw that conclusion rather than give them the answer. So, what we’re trying to do is break down defenses and avoid any power struggles, and by doing that, we’re trying to empower the consumer versus take their power away.”

When the time comes to make a change in our life, the Stages of Change model can be a useful tool both inside and outside of therapy. We recommend using it to track progress toward your goal and anticipate what will come next on your journey.

If you’d like professional assistance when working toward behavior change, you should know that our therapists and counselors here at Cummins BHS would be happy to help! Simply call us at (888) 714–1927 to discuss your counseling options and schedule an appointment.

If you’d like more advice related to changing your behaviors and improving your life, we recommend reading our New Year’s post about setting better goals!

How to Set New Year’s Goals You Can Actually Accomplish, According to Behavioral Health Professionals

Identifying Toxic Relationships: Dr. Armen Sarkissian Explains How to Escape the “Drama Triangle” Trap

Relationships with other people are a large part of what makes life worth living. This includes everything from parents and children to relatives, siblings, friends, acquaintances, co-workers, spouses and romantic partners. Healthy relationships enrich our lives and encourage us to develop as individuals. However, unhealthy relationships do just the opposite, making us dread or despise the other person and stifling our ability to grow.

Unhealthy relationships may also be called “toxic relationships,” a term coined by self-help author Dr. Lillian Glass in her book, Toxic People. According to Glass, toxic relationships are marked by conflict, competition, disrespect, and a lack of support and cohesiveness between the two people in the relationship. These malicious intentions can manifest in different ways depending on the nature of the relationship. For example, domestic violence is common in toxic relationships between intimate partners and family members, but less so between friends and acquaintances.

It’s not too hard to understand the difference between a healthy relationship and an unhealthy one—the difficulty is in understanding why unhealthy relationships develop in the first place. We often assume that bad relationships form because one or both of the participants are “bad people,” but this perspective is flawed and overly simplistic. In reality, many unhealthy relationships exist because the people in them are following unhealthy behavior patterns without realizing it.

In celebration of Valentine’s Day, we hope to shed light on some of the harmful patterns of behavior, or “roles,” that people sometimes adopt in interpersonal relationships. We spoke with Dr. Armen Sarkissian, Senior Psychologist at Cummins Behavioral Health, to learn more about one common pattern of dysfunction in relationships: the Drama Triangle.

The Unending Drama Between Rescuer, Persecutor and Victim

Dr. Armen Sarkissian, EdD, HSPP
Armen Sarkissian (EdD, HSPP), Senior Psychologist at Cummins BHS

In essence, the Drama Triangle (which is also called the Rescue Triangle or Karpman’s Triangle) is a set of three interrelated roles that people may play in a relationship: rescuer, persecutor and victim. Under this pattern of behavior, one person acts as the victim while the other acts as either a rescuer or a persecutor. When the victim is confronted with an obstacle in their life, they feel powerless to overcome it and believe they need someone else to do it for them. A rescuer or persecutor believes that the victim is powerless, and they either try to help them or condemn them for it.

This dynamic is harmful because it creates conflict between the people in the relationship and prevents either of them from solving the problem at hand. “The feelings that go with the triangle don’t let you use your potential because you’re stuck in one of the three roles,” Dr. Sarkissian says. “Basically, it is not a healthy way to behave in the world and relate to others.”

This pattern of relating is sometimes learned from childhood experiences. In particular, early research on the Drama Triangle found that it frequently plays out in families when one parent has a substance use disorder. “We’re talking about the early ’80s, when the drug of choice for most people was alcohol,” Dr. Sarkissian explains. “That pattern fit with most families of alcoholics. There was an alcoholic father, a rescuer mother, and the children. The wife would try to cover up for the husband’s drinking, and the children were the victims because they had no power.”

However, anyone can fall prey to the Drama Triangle regardless of their childhood and past experiences. Whenever someone believes that they or another person don’t have the power to help themselves, they are susceptible to falling into the Drama Triangle. Once in the triangle, they will alternate between the three different roles, and they’ll have a hard time getting back out of it. Dr. Sarkissian explains,

“We all, to a certain degree, do this without being aware of it. And once we’re in the triangle, we play all three roles. When relating to colleagues, especially, we can start to feel victimized, and then persecute the other person, and then feel bad and go into rescue mode. The interesting thing is that once you get used to this pattern, then you constantly get into it with others. People tend to identify with one role more often than the others, so once you’ve identified as a victim, for example, you’ll constantly find people who are either persecutors or rescuers—either ‘knights in shining armor’ or perpetrators.”

How to Break Out of the Drama Triangle

The Drama Triangle
Image from Claude Steiner’s "Scripts People Live." 1971. Grove Press, New York.

As mentioned above, the underlying theme of the Drama Triangle is a belief, conscious or unconscious, that people are essentially unable to help themselves. This is what leads a person to adopt one of the three roles and keeps them stuck in these roles. If they wish to break out of the Drama Triangle and begin having healthy relationships, they must learn to respect their own agency and the agency of other people.

“The idea is that I respect you enough to believe that you are able to take care of yourself,” Dr. Sarkissian explains. “I think one of the key points is that if I say ‘I can rescue you,’ in some way I’m saying, ‘I’m better than you. You don’t know how to do this. Let me show you.’ “ In the same way, someone in the persecutor role looks down on the victim, and the victim perceives themselves as inferior to their peers.

Of course, the person in the victim role is often in legitimate need of help with some situation or problem. If you choose to provide assistance, it’s important to hold the other person accountable for their own success or failure. Dr. Sarkissian suggests, “If you’re going to help somebody, respect them enough to believe that they can take care of themselves but just need help right now. Make an agreement about what you’re going to do and what the other person is going to do. If you jump in there and do it for them, you haven’t helped them at all. What you’ve done is emphasized and proved to them that they are not able to take care of themselves.”

There’s one final hitch that can keep people stuck in the Drama Triangle, and that’s the fact that it can be difficult to even realize when we’re in it. In many cases, a person becomes so familiar with the behavioral patterns of the Drama Triangle that they no longer appear abnormal. According to Dr. Sarkissian, the best way to detect these patterns is to pay close attention to the emotions you feel toward other people:

“If you want to work on your relationships, then you have to pay attention to your internal feelings when you’re relating to people. If you go through the three feelings of the triangle with one person—if you feel guilty and want to rescue them, and then you get angry because they’re not doing what you’re asking them to do, and then you feel like you’re powerless to do anything with that person—then you’re probably in a Drama Triangle with that person. If you feel these three emotions, then you’re probably going through the three roles.”

As we go through our lives meeting new people and forming new relationships, we always run the risk that one of them may become toxic. On this Valentine’s Day, we encourage you to examine all of your relationships for unhealthy behaviors such as those found in the Drama Triangle. If you discover that you are in a toxic relationship with someone, keep in mind that counseling or therapy with a mental health professional could help.

Happy Valentine’s Day to you and your loved ones from Cummins BHS!