Monthly Archives: January 2018

Understanding the connection between nutrition and mental health

By Robika Modak Mylroie and Rachael Ammons Whitaker January 17, 2018

In recent years, obesity has seized the attention of the medical field and the media. Now our schools are starting to recognize the impact of obesity on mental health. The United States is known internationally for its larger plate sizes, big portions and supersized meals in restaurants. However, we are also witnessing the beginnings of a cultural shift that encourages body acceptance and pushing back from an ideal body type.

At the same time, it may also seem that our society has become obsessed with healthier food options. But do we really understand nutrition? When we see terms and phrases in grocery stores such as organic, humane, low carb, high protein, non-GMO, no artificial coloring/preservatives and natural, it can be overwhelming. Some of these terms can be misleading or confusing. Our society is overmarketed with food slang and undereducated on what food labels mean to nutrition.

School and mental health counselors should be asking themselves how physical health and body acceptance intersect with weight, body mass index (BMI) and mental health. What if a person is deemed to be at an unhealthy body weight but is genuinely OK with his or her body? Conversely, what if this person is not happy with his or her body yet is considered healthy? When it comes to these body issues in children, at what point do school counselors intervene? How do we begin to support childhood social and emotional concerns surrounding nutrition without shining a light on those children who might be in a fragile stage related to their body awareness and image? How do we teach families and school employees to use language that promotes positive body image?

Although most medical journals openly discuss pediatric obesity as a major public health concern, they continually fail to address how to effectively combat such issues. The same statement applies with counselors. We know that childhood weight is a concern, but are we doing enough within our schools? Brain studies show that nutrition plays a role in learning, concentration and mental health in general, so why is it so hard for us to connect the dots?

Let’s explore the disconnect between childhood obesity, nutrition and mental health, and how we, as counselors, can support child nutrition in school settings. Can making the connection between nutrition and social-emotional needs move counselors to collaborate more effectively with other professionals? Counselors should care about what we are feeding our youth during school hours because it impacts our profession directly.

There also needs to be an awareness among parents and caregivers that nutrition is important not only in the school but at home. One of the issues that school counselors face is that not all parents and caregivers are supportive. Even if they are supportive, they may not possess the means to buy healthier food for the home or to prepare meals consistently. Preparation takes time, and not all families have that time to devote. Socioeconomic status, family makeup and genetic issues can also contribute to childhood weight and nutrition levels. For instance, there may be a lack of food in the house because the family cannot afford it, or there may be foods that are high in unhealthy fats and sugar.

Education is key to awareness, but this is difficult when we as counselors are not advocating for changes in school nutrition. We need to educate ourselves and make a connection in our profession between nutrition and mental health.

What we know

Childhood obesity is not a new concern in the United States. Many articles have been published on the health concerns of children who are overweight or obese. Michelle Obama’s “Let’s Move!” campaign brought national attention to the issue. During an open discussion this past spring, the former first lady said, “You have to stop and think, why don’t you want our kids to have good food at school?” During her time as first lady, Obama also hosted the School Counselor of the Year national recognition ceremony at the White House. This begs the question: Why have counselors, and, specifically, professional school counselors, not taken action on this issue?

Unfortunately, if the first lady struggled to implement this agenda, it stands to reason that it might be equally difficult for school counselors to get a foot in the door. Because of the disconnect between counseling and nutrition, it might even seem odd to some people that school counselors should get involved at all. As mentioned earlier, however, there is actually a deep connection between the two. Researchers have shown that poor diet not only leads to physical health problems but also affects brain functioning. Brain studies have shown that what people eat affects not only the social-emotional realm but also academic performance.

In March 2017, Laurie Meyers wrote a cover story for Counseling Today titled “When brain meets body” that discussed the connection between physical and mental health. More specifically, it delved into how thoughts can cause changes in the regulation of cortisol, which can then affect our clients’ physical health. This physical heath-mental health connection is emphasized in the mental health community but not as often in the school community and hardly at all in the medical community.

Why this research matters to us

The World Health Organization’s obesity map shows that as a whole, more than 30 percent of the U.S. population is obese. The Centers for Disease Control and Prevention (CDC) reported that 35 percent or more of adults in Mississippi, Alabama, West Virginia, Louisiana and Arkansas were obese. The CDC also noted that there was no state in the country with an obesity percentage of less than 20 percent among adults.

Mississippi tends consistently to be near the top of the charts for adult and childhood obesity, which is what sparked our interest in pursuing research in this area (both authors are from Mississippi). One question we asked is why a state such as Mississippi, which is rich in farmland and has an abundance of crops and fresh produce, has a prevalence of obese children. Our state should have abundant nutritional food available for families, including for those of low socioeconomic status. Lack of education and what people can afford likely have some connection to obesity rates in Mississippi. Statistics show that education and salary levels are highest in those states with lower obesity percentages. Mississippi ranks last in education statistics among the 50 states.

Healthy food consumption should not be dependent on social status. It should be affordable to all. However, many foods that are healthy and easy to prepare are also the most expensive. According to the website TalkPoverty.org, 20.8 percent of people in Mississippi live below the poverty line. Schools in this state, and in many of the other states identified as “obese and overweight,” may not be able to afford these healthier options in bulk.

This raises other questions. What can we do differently to secure healthier food access in our schools for reasonable prices? How do we partner with local farmers to provide more nutritious foods or to demand that our schools contract with better food providers? Healthy breakfasts, lunches and snacks during educational hours should not be contingent on whether a child has a homemade lunch or went through the cafeteria line.

The connection for Robika

Working as a school counselor in rural Mississippi, I noticed that a disconnect existed between the medical field’s information on physical health and the knowledge of mental health within the schools. I saw many children who would likely be classified as overweight or obese, and I saw a lot of students who were unhappy about their weight. I often consulted with the school nutritionist and nurse in these instances. With these particular students, I also noticed the prevalence of several issues that extended beyond academics to socioemotional problems, including bullying, self-esteem issues and anxiety. This observation sparked my curiosity about the possible connection among these different variables.

I wrote my dissertation about the connection between childhood obesity and personal, social and academic issues. Although I didn’t find a statistically significant connection (probably because of limitations in research), I did identify individual connections in my sample between self-esteem and interpersonal relationship satisfaction. This led my wanting to know more and wanting to continue this research and advocacy within the schools.

The problem was — and continues to be — that obesity is a difficult topic for schools to address. Obesity is a buzzword that is sometimes considered offensive. It was difficult getting parents and caregivers to agree to let me weigh their children.

As Rachael and I began collaborating on this topic, questions started forming: Why are school counselors not more involved? BMI doesn’t provide a fair reading of weight for different ethnicities, so why are we using it to define weight? What other way can we measure weight to incorporate multicultural, nutritional and genetic considerations? How can we fill in this gap among the medical, school nutrition and mental health worlds? Would school counselors be comfortable talking about this topic?

These questions continue to drive us as we move into more detailed research and advocate for school counselors and for our students.

The connection for Rachael

During my doctoral research classes, a professor said to me, “Rachael, bring in any research that sparks curiosity.” This simple statement opened a wormhole of personal curiosity, followed by fear and then drastic dietary changes. Becoming a good consumer of research resulted in me experiencing emotional ups and downs, especially when I decided to read more about Food and Drug Administration food protocol, particularly around animal products.

This launched my personal pursuit of knowledge surrounding nutrition. However, the real lightbulb moment took place when a direct correlation was drawn between some of my food intake and my autoimmune disease that I had been medicating for years. It was also around this time that Robika asked me to help collect data for her dissertation. Her research lit a fire in me to implore my friends, family members and students to care more about what they were putting into their bodies. Now, as the research advances, Robika and I hope that we can support counselors in K-12 settings in getting involved in school food purchases and menu planning.

What we can do about the knowledge gap

A lack of information exists concerning how school counselors can promote wellness and nutrition in terms of social and emotional health. Researchers for HealthCorps, an advocacy group that incorporates wellness education into schools, based their study on three domains: nutrition, physical activity and mental health. However, the term mental health was a misnomer because it did not encompass all aspects of mental health. Instead, it was essentially defined as mental resilience. In addition, no counselor was included on the study’s development team, which consisted of dietitians, nutritionists, integrative human physiologists and other health care professionals.

Through our own research, we believe that we are on the path to helping school counselors promote wellness, healthy weight and mental health through prevention and intervention methods with students and their families and within the school itself. Our long-term goal is to make connections between the brain, childhood weight and mental health, and then to use this information to help school counselors collaborate with school nutritionists and communities to create better lifestyle choices and, in turn, promote socioemotional wellness. We decided that we needed to start with school counselors themselves to get a better understanding of how comfortable they are talking about these issues, and especially childhood obesity. Again, the word obesity brings up a number of issues for many people.

We have received really wonderful feedback when presenting on this topic. Not a lot of counseling research has been done in this area. As a result, we have found that many counseling professionals are very interested and agree that it needs to be researched more thoroughly. Unfortunately, presenting this line of research to the schools has been difficult. Parents tend to keep their children from participating in research related to obesity and nutrition, and school boards, faculty members and school staff often have a difficult time with it too. Realizing that school counselors may not feel comfortable using the term childhood obesity, we have since changed this term to childhood weight. In this case, we can also talk about the opposite spectrum of obesity, which includes disorders such as anorexia nervosa and bulimia.

Another aspect of what we are attempting to do is to place these terms within the context of ethnicity, age and gender. In our initial research, we measured BMI because this was the only option for calculating obesity. However, we know that some ethnicities may be more susceptible to qualifying as overweight or obese even though they are of normal or healthy weight. Another example is that athletes who are larger and more muscular are not necessarily overweight or obese, but their muscle mass may tip the scales toward them being classified as overweight.

As counselors, we have to be aware of the demographics of our communities. This is not a new concept of course, but we can start making little ripples to address a larger problem, especially in the schools. In some towns, nutritious foods are not available or affordable. High-calorie, high-fat foods are more readily available and come at lower prices. Once the cycle of eating high-calorie foods begins, it can be difficult to change it. Children who are taught about nutritious foods may mention this to their parents, but the parents may ignore the request because they cannot afford these foods or because the foods do not sound appetizing. Other parents may work multiple jobs and not have time to make meals for their families. Some families have to rely on their older children to make dinners.

Home life aside, however, schools need to work to have healthy options. Some schools will present the choice between a baked meal and a fried meal. Many students will opt for the fried meal. Although choices are important, we propose that children be presented with more healthy options. Countries around the world have lunches made from scratch that include vegetables, seafood, whole wheat breads, fruits (rather than sugary syrup) and nonprocessed meats and cheeses.

Children should also be educated about their food. This empowers them to make healthy choices based on their own knowledge. They can even be involved in planting vegetable gardens at school or preparing meals at home.

However, there seems to be no connection or collaboration between the different fields of research, even though there are several areas of knowledge that intersect.

We believe there are ways that these three knowledge bases can work together and help each other. The image on page 52 [of the print version of this article, ] shows our proposed Integrative Collaboration Childhood Weight Model, which is where our research will go next. We want to bridge the gap and highlight what the features of each area are, as well as bring them together to create a richer research model.

Our hope is to first understand school counselors’ comfort level when discussing the issue of childhood weight. We also want an idea of their understanding of the connection between childhood weight and socioemotional and academic issues. We need to know what kinds of community, caregiver and school support school counselors receive. Do they already collaborate with the other faculty and staff in the school? If so, is this on a regular basis?

Future goals include creating prevention and intervention methods and materials that will address nutrition and socioemotional wellness in conjunction with other staff in the school district. Working as a team is more likely to result in better overall outcomes. Healthier children can mean healthier adults. So, let’s be willing to talk about the connection between food and mental health.

Potential interventions, prevention methods

Given that not a lot of research has been conducted in this area, school counselors are somewhat at a loss for potential interventions for childhood obesity. Children who are overweight or obese may come to the school counselor for issues such as self-esteem, a lack of confidence or bullying (either being the target of bullying or engaging in bullying themselves). However, we cannot assume that their weight is the reason for these issues unless the child mentions it as a cause. School counselors cannot target children who are overweight or obese for individual counseling.

Although interventions can be put into place by the school counselor for the specific issues mentioned (self-esteem, confidence, bullying), we believe that prevention methods may have the most impact for all children when it comes to childhood weight. Classroom guidance lessons focused on nutrition, wellness and self-care can be part of the comprehensive school counseling program. We also want to again emphasize the potential impact of collaborating with other school staff such as school nurses, school nutritionists and physical education teachers. Providing wellness interventions for both physical wellness and mental wellness is also likely to have a greater impact on students. Teaching these methods of self-care not only helps the whole child but also gives students the tools to continue healthy living and wellness practices across the life span.

An activity that might serve a dual purpose is horticulture therapy, in which children create sustainable gardens while also working with the earth as a form of healing. Children can learn how to grow vegetables and fruits and better understand their nutritional value even as they also grow their personal and social skills. Some children may even want to grow their own gardens at home.

Parent/caregiver involvement has been shown time and time again to be related to the success of the child. School counselors and nutritionists could present workshops for parents and caregivers focused on how they can make nutritious meals for their kids and even with their kids. Information on meals and snacks that are inexpensive but also better for the family can also be shared. Teaching parents about the value of nutrition and mental health should also be emphasized. Another area of emphasis might be teaching parents and caregivers how to engage in positive body language. Parents and caregivers are models for their children, and if they speak negatively about their bodies, then their children are likely to copy that negative self-talk.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences

Robika Modak Mylroie is a distance clinical professor in the Department of Counseling and Special Populations at Lamar University. Her experience consists of working in the clinical setting before becoming a school counselor. Her current research includes childhood weight, trauma and animal-assisted therapy. Contact her at rmylroie@lamar.edu.

Rachael Ammons Whitaker is the program director for the clinical mental health and school counseling programs at the University of Houston. She worked as a behavioral therapist, behavioral interventionist supervisor and school counselor before pursuing counselor education at the university level. Her current research includes understanding and advocating for intersex children and the impact of childhood weight. Contact her at rachaelammons@yahoo.com.

Letters to the editor: ct@counseling.org

 

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

Counseling with artificial intelligence

By Russell Fulmer January 16, 2018

Welcome to tomorrow. Artificial intelligence (AI) is now actual science, not science fiction. Although its formal inception took place in 1956, the idea of AI is known to most people only through imaginative movies such as The Terminator or the 2013 flick Her. However, right here and now, AI is real and maturing at a near exponential rate. Signs point to AI soon infiltrating society at large, which means that the counseling profession is not immune. The future of counseling likely involves virtual assistants, virtual counselors, chatterbots and, for the inclined, robots dubbing as animals to help comfort clients.

AI equates to machine learning. Current AI assistants such as Siri and Echo have limited capabilities. The holy grail of AI is artificial general intelligence — machines with humanlike, versatile abilities. AI can be contrasted with organic intelligence, or, put another way, human, biological intelligence. Many factors contribute to human intelligence, chief among them being our ability to process information, solve problems, adapt and learn. All of this happens in the brain, and in many ways, our brains are like computers. AI researchers apply the findings of neuroscience to computer programming to make computers more like us.

The goal of AI, then, is not just the production of an ordinary computer, but one that learns and can become autonomous. And guess what? Computers can learn much faster than us. Their intelligence is off the charts. Plot typical human intelligence quotients on a normal curve, situate Einstein’s a couple of standard deviations to the right, and try to imagine the placement of a conscious artificial intelligence (CAI). Now, envisage what a CAI is capable of doing, inventing, discovering and revolutionizing. The prospect is equal parts bewildering, intriguing and nerve-wracking.

Computers have already beat the best humans at chess, Jeopardy! and, more recently and impressively, the board game Go. Played copiously in Asia, Go is a strategic, intuitive game with a mind-blowing number of possible moves (researcher John Tromp finds that number on a 19-by-19-inch board to be ~2.082 × 10^170, which equals a 2 followed by 170 zeros). Garry Kasparov (chess), Ken Jennings (Jeopardy!) and Lee Sedol (Go) are all very smart, and each fell to AI in his respective specialty.

But those are games. AI can’t “beat” the best counselor, can it? Surely not …

Relevance to counselors

Asking if AI has significance to the counseling community is like asking if counselors should be concerned with global warming or if social media has an impact on the lives of our clients. AI is originating within the hard sciences but promises to touch the emotional lives of clients in untold ways. The magnitude of AI’s impact remains unknown. Some individuals are excited by the vast reach of AI, whereas others are cautious. Consider the following quotes:

“It would take off on its own and redesign itself at an ever-increasing rate. Humans, who are limited by slow biological evolution, couldn’t compete and would be superseded. … [AI will be] either the best, or the worst thing, ever to happen to humanity” — Stephen Hawking

“We need to be super careful with AI. Potentially more dangerous than nukes.” — Tweet by Elon Musk, Tesla and SpaceX CEO and co-founder of Paypal

“I am in the camp that is concerned about superintelligence. [At] first, the machines will do a lot of jobs for us and not be superintelligent. That should be positive if we manage it well. A few decades after that though, the intelligence is strong enough to be a concern. I agree with Elon Musk and some others on this and don’t understand why some people are not concerned.” — Bill Gates

Should counselors be concerned? They should at the very least be educated about the subject. Knowledge is power. In the short term, the consensus is that AI will rapidly expand automation. When this occurs, the jobs of your clients who are employed in, for example, the fast-food industry might be threatened. Perhaps new jobs will be created, however. After all, people originally feared that the Industrial Revolution would lead to massive unemployment. In fact, the opposite happened.

Unlike a century ago, however, things are changing at a faster pace. The modern age is quickly morphing into a future of omnipresent technology. Change management may become an overarching theme of therapy in the near future. Change is coming fast because algorithms are being written that enable AI to expand its abilities into the realms of creativity, cooperation and emotional intelligence. It is here that AI directly converges with counseling.

Computers that care

In his book, Thinking Machines: The Quest for Artificial Intelligence and Where It’s Taking Us Next, Luke Dormehl writes about how advances in facial recognition enable AI assistants to read the emotional states of users. The company Affectiva broadcasts on its website that its “emotion AI humanizes how people and technology interact.” Affectiva is at the forefront of bridging this gap by … let’s call it providing a corpus callosum between traditional computer acumen, with its mathematical and logical abilities, and the realm of emotional intelligence.

Facial recognition software is getting better. “Ellie” is an example. A virtual reality AI, Ellie was created by the Institute for Creative Technologies at the University of Southern California to help treat people with depression and posttraumatic stress disorder. On the computer screen, there sits Ellie, whose body language mirrors that of an actual therapist. She responds to emotional cues, nods affirmatively when appropriate and adjusts in her seat. She does all of this because her algorithm permits her to perceive 66 points on a person’s face and read his or her emotional state accordingly.

It’s obvious that Ellie is not “real,” and therein lies the secret to her success — people feel less judged talking to Ellie. She provides the ultimate in unconditional positive regard. Although Ellie looks like a therapist, she doesn’t claim to be one, telling people from the outset, “I’m just here to listen.”

Ellie has company in “Tess.” The developer, X2AI Inc., says Tess is a “psychological AI that administers highly personalized psychotherapy, psycho-education and health-related reminders, on-demand, when and where the mental health professional isn’t.”
This slogan speaks volumes about the future interplay of technology and mental health counseling. Counselors have families and need to sleep. Some even like to take vacations. AI has no need for any of the above.

As therapeutic AI becomes more mainstream, it is likely that some people will forgo seeing living, breathing counselors altogether in favor of their favorite virtual therapist. Others will see an actual counselor plus their online “listener.”

Of course, ethical questions abound. Nevertheless, like it or not, AI promises to play a greater role — either directly or indirectly — in the counseling sessions of the future.

A client’s truth

Skeptics may point to the obvious — that no machine is truly human; that humans need humans; that a machine can fake, say, empathy but not actually deliver it; and that clients will see through the façade.

The counterpoint to this criticism resides in a question: Who determines clinical truth? Rather than ask whether machines can be empathic, a more pragmatic question for counselors may be, will clients perceive them to be empathic? If so, what are the ramifications?

The evidence suggests that in some cases, people do indeed emotionally connect to computer programs. It has been happening since the 1960s, when “Eliza” was created. Created by a computer scientist to demonstrate the blurry threshold between man and machine communication, Eliza was a computer program that reflected statements typed to her via text. Programmers were astounded when people began ascribing human emotions and feelings to a computer program, confiding personal information to Eliza and pouring their hearts out. Blurry boundaries indeed.

Eliza is still with us, available on several websites and ready to chat. Programmers declare Eliza a Rogerian therapist open for business. You just have to believe the illusion. That illusion may be a client’s truth.

Music therapy

For the music therapists out there, AI has touched even one of the longest-running human traditions — making music. Sony Computer Science Laboratories is coordinating the Flow Machines project in conjunction with the European Research Council. The goal is to see if AI can autonomously create music.

Currently, AI still needs some human assistance. Your favorite singer undoubtedly has a better voice than your favorite robot. However, AI is helping and making great strides. Check out “Daddy’s Car” and “Mr. Shadow,” two pop songs created with the help of AI. The first is in the style of the Beatles, circa late 1960s. As for “Mr. Shadow,” listen and judge for yourself. Both songs are available on YouTube. Neither song may be suitable for music therapy, but their mere existence suggests that this is only the beginning of music created by sentient machinery.

The question is, if AI can help produce music today, will it find a place in the music therapy of tomorrow? Will the act of music production itself — between a counselor, client and AI — prove therapeutic?

Counselors aren’t the only ones interested in how far AI creativity will expand. For more information about how AI is being used to create both art and music, research Magenta, a project from Google Brain.

Animal-assisted therapy

Meet Paro, a therapeutic robot. You may know a lot of robotic baby seals (who doesn’t?), but none is like Paro, because this cuddly seal is interactive. Paro (known as a “carebot”) makes eye contact, has five senses, responds to its name and, like any good AI seal, learns. Paro’s website (parorobots.com) indicates that research has shown that the carebot aids in reducing stress, improves relaxation, motivation and socialization, and helps people who have dementia. Paro certification classes are even available. If you are wondering whether Paro runs on batteries, rest assured that Paro charges by sucking on an electric pacifier.

Even our animal compatriots will be affected by AI. It won’t be the first time that technology has altered the function of an animal, or its numbers. The advent of the internal combustion engine spelled the end of the horse-drawn carriage. The number of horses in the United States plummeted as a result. It’s easy to predict that therapeutic robots will play larger roles in counseling. On the bright side, they create fewer messes.

Looking ahead

Currently, counseling is chemistry, an interaction between two or more carbon-based life forms, albeit a special interaction marked by active listening. The therapeutic alliance is the emergent property that stems from this interaction. Chemistry and counseling — who said the social and hard sciences were disparate? This is counseling at an elemental level.

But what about counseling not at the basic level but at a technologically advanced level? What form does that take? AI offers an answer. Machines that can think and learn, that even look and act like a human counselor, could revolutionize the field.

The future is unwritten, but the counseling community would be wise to anticipate and plan ahead. Here are some pointers for doing just that.

1) Educate yourself about emerging AI technologies. Advancements happen quickly, so staying updated on everything might be impossible, but keeping an eye out for major breakthroughs, themes and patterns is advisable.

2) As AI infiltrates society at large, be on the alert for clients who are growing aware of the technology and feeling excited or fearful of it as a result.

3) Don’t be surprised when some clients start viewing a chatbot, carebot or — potentially — therapistbot as their other counselor. Likewise, clients may anthropomorphize their robotic pets. Start thinking about how you will respond when clients speak of computers as if they are people.

4) Advocate for your profession. Tech companies are producing everything from apps to robots, and they are hiring mental health professionals to help humanize their creations. The company mentioned earlier that developed Tess is currently looking for — you guessed it — clinical psychologists. Perhaps the people at this company simply don’t realize that counselors are distinct and have a lot to offer. Advocate.

5) Be proactive and address the ethics surrounding the coming AI movement. The choice is clear: Anticipate and plan accordingly or wait, be reactive and deal with issues after they have arisen. Prevention is good medicine. At the national level, the American Counseling Association’s Ethics Committee could keep AI on its radar screen.

Predictions about world-altering technology are usually premature, but AI shows no signs of slowing down. Sooner or later, AI will bring changes — perhaps significant changes — to the counseling field. The key is to adapt and evolve. Remember, no AI is better than the best counselor … yet.

 

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Russell Fulmer is core faculty with the Counseling@Northwestern program with The Family Institute at Northwestern University, where he specializes in the psychodynamic approach. He has written “conversations” used in AI algorithms for chatbots. Contact him at russell.fulmer@northwestern.edu.

Letters to the editor: ct@counseling.org

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

 

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

The Counseling Connoisseur: New Year’s resolutions

By Cheryl Fisher January 12, 2018

“When the well is dry, we know the worth of the water.” — Benjamin Franklin

 

The holidays are over. The ornaments are boxed and put away. The tree is at the curb ready to be recycled for mulch. The eggnog and cookies are gone leaving behind only the memory as I tug my snug jeans over my more rounded hips. I sit back in my recliner and sip my holiday tea which offers hints of mocha and peppermint, evaluating this past year’s events.

It was a year filled with grief and transition: The death of a beloved pet, job transitions and surgeries. It was also a year of beginnings and opportunities: New speaking engagements, a book contract and a new academic position. In 2017, life continuously oscillated between joyous highs to devastating lows. What a ride!

I evaluated my self-care over this past year and (like many) I find I fell short in some areas. I exercise regularly and eat well, but I still don’t drink enough water. I overschedule, loving everything I have the privilege to do — but leaving little space for much needed quiet. I want to write more and that requires (at least for me) quiet and time. So, I put pen to paper and begin my process of resolving to offer myself better care in the New Year … and so it begins.

 

Wellness Wheel

The idea of self-care, although essential, tends to elude caregivers and those of us in the helping professions. We preach it to our clients. However, we become our own exception to the rules of wellness. Further, overall wellness encompasses all aspects of our life to include relationships and finances. The United States Substance Abuse and Mental Health Services Administration (SAMHSA) has created a wellness model that includes eight dimensions that contribute to physical and mental health.

  1. Emotional

Helpers need help, at times, in processing difficult experiences. Recently, a grieving therapist-friend lamented: “We are all liars! We tell our clients all about grief and loss, assuring them that things get better … but they don’t!”

I allowed her to continue her disgruntled evaluation of the pain and suffering that accompanies grief and then asked, “So, you are saying that just because we as clinicians know the grief process we are not immune to the actual pain?”

We bleed just like any other human, I reminded her. We feel hurt, and pain — and we suffer. Even if we have an intellectual understanding of the process, we still must endure the journey.

What supports do you have in place? Who can you call upon for guidance? How are you coping with your life’s challenges?

  1. Environmental

Our internal wellness is informed by our external surroundings. When I decided to start a private practice, I created a vision around the environment in which I wanted to spend six to eight hours each day seeing clients. I thought of my favorite colors, turquoise and green, and the most peaceful setting: the beach. I went to my nearest Pier 1 Imports store and let the designer go to town picking out dark-stained wicker furniture with pillows and wall art of batik with inspirational hand-painted words such as love, inspire, believe, peace. I added a few pieces of sea glass and shells from my travels and voila!

How do your personal and professional environments support you? Do they offer a peaceful haven or chaos and disorganization?

  1. Financial

Financial wellness is an area that many individuals find difficult to examine. Early in my career I was barely making enough to pay my bills, let alone think about a portfolio. However, what I have learned is that seeking the expertise of a financial professional helped me begin to see how I could create a solid personal plan — even with meager beginnings. There are numerous resources that can help address your financial needs and help you develop a realistic plan. It is easier than you think!

How are you contributing to your financial health?

  1. Intellectual

We are creative beings. We need stimulation and imaginative ways to express and expand our knowledge and skills. For example, a year before ACA’s 2016 Conference & Expo in Montréal, I committed to learning a bit of French. I spent every morning rehearsing. My mother, who is French- Canadian, tested me as we ventured through the produce isle of a grocery store.  More recently, I became a student of backyard foraging. Yes, I walk the trails looking for bounty: wild berries, mushrooms, rose hips and greens. My passion for nature therapy ignites as I learn more about the intricate communication between the plants and animals. I get excited when I put together a delicious feast from my foraged treasure.

In what ways are you stimulating your mind?

  1. Occupational

I love my work! Each day I experience variety in client needs. I enjoy sharing theory and application with my students. Writing joins my clinical and academic work to complete my professional trifecta. I love my work so much that I often overschedule: I see 30 clients in my practice, I teach six classes for three universities, I am a national presenter, I have a column that I contribute to monthly, and now I have a book contract and a full-time university faculty offer. Clearly, something has to give (stay tuned!).

How does your occupation meet your needs? Are you satisfied with your work-life-balance? Or, like me, is it time for you to re-evaluate?

  1. Physical

Our bodies need attention. We need food, water, rest — and to be active. Exercise is such an important part of my life. I like to move. It feels good to sweat. Yet, I have an incredibly sedentary job — I sit all day long. In addition to my hour-long gym class, I’ve created movement throughout my day to mediate the effects of hours of sitting. Others with sedentary jobs are employing standing desks, or taking short walks around the office just to stretch. My Fitbit reminds me to attend to all of the elements of physical health.

How are you taking care of your physical wellness? Do you carry a water bottle to hydrate? Do you take walks regularly and get fresh air?

  1. Social

We are social creatures. Abraham Maslow pointed out decades ago that once the immediate needs of food, shelter and safety have been met, we need to feel like we belong. That sense of belonging comes from having the support of others. For some, family may not serve as a support system. While my family is a source of great support, I also like to create a network within my community. For example, when I moved to Annapolis (almost 20 years ago), I did drive-by visits to my most important sources of connection. I interviewed churches. I located gyms. I identified several coffee shops. I found dog parks and trails.  Clients have since told me about the Meetup.com concept of identifying groups of like-minded persons.

How is your social wellness?

  1. Spiritual

In The Gifts of Imperfection: Let Go of Who You Think You’re Supposed to Be and Embrace Who You Are, author and researcher Brené Brown writes:

“Spirituality is recognizing and celebrating that we are all inextricably connected to each other by a power greater than us, and that our connection to that power and to one another is grounded in love and compassion.”

Research continues to find that experiencing the sacred provides us with wellness, healing, support and a sense of meaning.  Years ago, I helped my faith community start a Prayer Shawl Ministry (a spiritual practice that involves shawls that provide comfort and solace to those in need). As a card-carrying feminist, I am drawn toward the feminine sacred, even within traditional religious practices. So, it was such a great opportunity to convene with other women in meditation and click our needles together with intention as we crafted shawls for ill church members. Influenced by my Celtic heritage, I find beauty and the divine in natural settings. Engaging in nature is sacred for me and promotes moments of awe and wonder. It nourishes my spirit.

 

How do you cultivate awe and wonder in your life? What do you find sacred and meaningful? How do you craft opportunities to nourish your spiritual health?

  

Conclusion

It is a new year. A time to ponder past experiences and future dreams, re-evaluate relationships and let go of old habits and develop newer, more nourishing, ones. As I review my wellness wheel, I find that there are several areas with which I am pleased — and a few that I will choose to modify in order to bring greater balance to my rich, full life.

 

Be kind to your body, gentle with your mind and patient with your heart.

Stay true to your spirit, cherish your soul and never doubt yourself.

You are still becoming, my love, and there is no one more deserving

of the nurturing grace of your love.

“Kindness” -Becca Lee

 

Happy New Year!

 

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Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is affiliate faculty at Loyola and Fordham Universities. Her research interests include examining sexuality and spirituality in young women with advanced breast cancer; nature-informed therapy; and geek therapy. She may be contacted at cyfisherphd@gmail.com.

 

 

 

 

 

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

Changing the conversation about aging

By Lindsey Phillips January 10, 2018

Picture a grandson trying to help his grandfather adjust the tracking on his VCR. In the corner, the grandson’s friend jokes that they are ignoring the larger issue — that no one uses VCRs anymore. When the grandfather starts talking about his life, the young men make up an excuse to leave, but the grandfather captures their attention with a story about his experience during the war. By the end, the young men are eager to spend more time with him.

This is the opening scene from an episode of the Netflix comedy series Master of None. The episode, titled “Old People,” effectively exposes and challenges ageist stereotypes.

For some people, even the phrase older adult conjures up negative images of physical and cognitive impairment. But ageist stereotypes, such as older people being out of touch, do not reflect the typical experiences of older adults. Aging is a natural part of life, and many people age well. In fact, only approximately 5 percent of older Americans live in nursing homes at any given time, according to the American Psychological Association.

AARP is attempting to reverse this negative narrative with its #DisruptAging campaign, which provides a space for changing the story about aging and embracing life throughout the life span. In a recent post, AARP used the phrase gray-cial profiling to call out companies guilty of age discrimination. These offenses range from identifying older adults as potential shoplifters to excluding older adults from certain career opportunities.

Unfortunately, the issue of thinking negatively about aging often extends to health care professionals, many of whom view aging as a problem to be solved rather than a normal part of the life span. In addition, they often focus on the physiological aspects of aging rather than the psychological, social and spiritual needs of older adults.

Many interventions across disciplines focus on deficits, observes Sara Bailey, a doctoral candidate at the University of North Carolina at Greensboro (UNCG). For example, some gerontology, nursing and medical programs use an aging suit — a suit that simulates the physical impairments of older adults, such as strength and sensory loss — to expose students to the impairments of older people. “That basically conditions the student to understand that age and impairment are the same thing,” argues Bailey, a member of the American Counseling Association.

In his work in long-term care facilities, Matthew Fullen, an assistant professor of counselor education at Virginia Tech, noticed that conversations between older adults and health care providers often focused on physiological deficits. From his perspective, this scenario contributes to the medicalization of aging and tells only a narrow piece of the overall story. “If we assume that [physiological changes] are only going to be moving in a deficit direction, then we sort of get the self-fulfilling prophecy where we see those problems and we don’t see the rest of the person in front of us,” Fullen explains.

Most older adults don’t develop dementia or lose their ability to walk, be funny or engage with others, so “it’s important to expose [counseling] students to the reality of [aging] instead of pathologizing it,” Bailey says. To assist with this process of introspection, she challenges counseling students to find a birthday card for someone beyond the age of 18 that doesn’t rely on disparagement humor. Bailey refers to this type of humor as future-focused self-loathing: “When we laugh at getting older, we’re really laughing at ourselves, and we’re not laughing in a kind and loving way. We’re laughing in a way that others our future selves, and that’s not OK.”

The forgotten population

The level of importance placed on gerontology in counseling has not been clear or consistent. In 1975 in the Personnel and Guidance Journal, Richard Blake called attention to counseling older adults, a population he deemed “forgotten and ignored.” Then, gerontological counseling gained forward momentum. In 1986, the Association for Adult Development and Aging (AADA) became a division of ACA. Between 1990 and 1992, the Council for Accreditation of Counseling and Related Educational Programs (CACREP) adopted gerontological counseling standards for community counseling programs, and the National Board for Certified Counselors (NBCC) created a specialty certification in gerontological counseling. However, because of declining interest, NBCC retired this certification by 1999 and CACREP removed the gerontological counseling standards by 2009.

This de-emphasis on later adulthood in counseling education motivated Bailey to pursue a doctorate in counseling and become part of the solution by specializing in later adulthood. At her first counseling education and supervision conference, she discovered that the gerontological counseling certification no longer existed. She says this led her to wonder, “What does this say about the focus of counselor educators? What does it say about the value of our clients and who we value more?”

In the United States, the older adult population is projected to more than double from 46 million to over 98 million by 2060, according to the Population Reference Bureau, and the Institute of Medicine notes that nearly 1 in 5 older adults has one or more mental health or substance use disorders. This raises a question: Why isn’t the counseling profession doing more to prepare counselors to care for this rapidly growing and vulnerable population?

Fullen, an ACA member who also serves as secretary of AADA, argues that counselors lack awareness about aging issues. This lack of awareness may stem from a range of factors, including the fact that older adults are a segmented part of the population, he says. Fullen also posits terror management theory as a possible explanation: Counselors fear the aging process because it reminds them of their own mortality.

In a course on life span development, Amber Randolph, an assistant professor and program director of the clinical mental health counseling program at Judson University in Illinois, discovered that her entire class of 25 students was terrified to discuss the end of life. “We’re turning out counselors who are going to be dealing with grief and loss issues who are very uncomfortable with the idea of death and, in particular, the idea that they too will age and die,” notes Randolph, a member of ACA.

This anxiety over aging can lead to the avoidance of older adults’ needs. Humans are the only species aware of their own mortality, so avoiding working with older adults is often not a conscious decision but rather an aversion to fear, Bailey adds.

Bailey is directly addressing counselors’ resistance to incorporating later adulthood within counselor education. Her research focuses on reintegrating gerontological competencies into existing coursework, which she believes will be a less objectionable approach. “I think it’s going to take a sea change in the way we view culture to start to include age in our developmental courses, in our career courses, in our theories courses, in our diversity courses,” she says. That might mean really integrating “the competencies that used to exist … in a subtle, gentle, very fluid … way so that every counseling course covers the age span,” she adds.

Bailey thinks that emotionally connecting counselors with aging issues is key. “You can talk about issues of late adulthood, but until you connect emotionally with the student around those issues … it just doesn’t click.”

To improve empathy and attitudes toward older adults, Bailey developed a perspective-taking intervention that includes three parts. First, in a journaling activity, counseling students describe their future 75-year-old selves. The second part is a game in which the students read prompts describing ageist events and then immediately reflect on the emotional reactions they would have if they were the older adult. In the third part (a reflective journaling activity), the counseling students consider their feelings and reactions toward counseling a 90-year-old client who shows symptoms of depression.

Age as an intersecting identity

Intersectionality is often discussed in terms of the interconnections between a person’s identities of race/ethnicity, gender, sexual orientation and class, but age typically gets overlooked. “Age is the only one of these marginalized identities that every single person will experience granted that they live long enough,” Fullen says. Even so, he points out that little research exists within the counseling profession on intersectionality that includes aging. “The client’s age just becomes another intersection piece that fits in very appropriately with all of those other constructs. So I’m more concerned with the ability of counselors to consider age as another intersection.”

Christian Chan, an assistant professor of counseling at Idaho State University and an ACA member, also encourages counselors to discuss intersectional identity with clients. “There are microaggressions that exist because of those intersections,” he says. For example, an older adult may refuse to socialize with someone who is gay. Thus, diversity exists between and within identity categories, and the way people navigate their overlapping forms of privilege and oppression provides them with their unique experience, he explains. By putting these identities into conversation, counselors can help clients understand what is happening to them.

This conversation about intersectionality is crucial because the growing population of older adults is also becoming more diverse. According to the Centers for Disease Control and Prevention, between 2014 and 2060, the percentage of adults age 65 and older who identify as white non-Hispanic is expected to drop from 78 percent to 55 percent. In addition, according to the University of Washington’s School of Social Work, approximately 2.7 million U.S. adults age 50 and older identify as lesbian, gay, bisexual or transgender, but that number is expected to increase to more than 5 million by 2060.

Counselors should avoid speaking about diversity in a broad sense, cautions Chan, who serves on the AADA executive board. He explains that when counselors focus on the centrality of one type of identity, they lose sight of the other identities and the way these intersections affect experiences, which can lead to the rank order of identities. For example, counselors often talk about LGBTQ+ (lesbian, gay, bisexual, transgender, queer/questioning and others) communities and older adult communities in isolation rather than discussing the overlap between these identities.

Instead of asking broad questions (e.g., “How do you identify culturally?”), Chan advises counselors to use specific questions (e.g., “How would you identify in terms of your racial/ethnic identity?”) to engage in a richer conversation with clients. The simple act of including open-ended space for identity on preliminary assessments and intake interviews — for instance, by replacing check boxes with fill in the blanks — can help counselors understand a client’s multiple identities and possible intersections, he adds.

Mijin Chung, an ACA member and licensed professional counselor (LPC) with a private practice in the greater Atlanta area, also sees a danger in discussing diversity broadly. When working with older adult immigrants, for example, counselors should examine the home country and family culture of clients and avoid making broad generalizations based on age or culture, she says, because a significant number of within-group differences exist. Therefore, it is crucial for counselors to understand the environmental context of older adult clients. For example, immigrant older adults who came to the United States when they were young may have a different view of aging and U.S. culture compared with immigrant older adults who recently came to the country and perhaps live with their adult children.

Chung finds the narrative approach helpful when working with older adults, and especially with older adult immigrants, to uncover clients’ unique experiences. Often, Chung says, this population does not receive many opportunities to share their life or immigrant stories. With a narrative approach, counselors can glean the obstacles and challenges older adults have overcome, and clients’ stories can provide counselors with a frame of reference for how to proceed in session.

Counselors must also remember that intersectionality is more than just multiple identities, Chan says. “You can’t have intersectionality if you’re not talking about power; you can’t have intersectionality if you’re not talking about social context; you can’t have intersectionality if you’re not talking about social justice,” he explains.

Fullen agrees that intersectionality is about the way that multiple identities lead to power differences or marginalization. In fact, disparities often emerge when marginalized identities such as race and sexual orientation are combined with an older adult experience. For example, an older LGBTQ+ individual may face barriers to finding safe housing options, such as denial from entry or a higher probability of eviction. These barriers are further complicated if this older individual has a disability that limits mobility or a lower income because of decreased access to income opportunities, Chan says.

Counselors should think about how they can help to make systemic changes to ensure that multiple marginalized communities are visible and have rights and access to opportunities and basic care, Chan argues.

A hidden reserve of resilience

Resilience — an individual’s ability to recover from adversity — is often a coping skill that we attempt to teach to children, but research shows that resilience can have a positive effect in later adulthood as well. According to an article by Tara Parker-Pope in The New York Times this past summer, scientists claim that resilience operates like an emotional muscle that can and should be strengthened with techniques such as being optimistic, reframing your personal narrative and remembering challenges that you have overcome.

Of course, building resilience isn’t easy and takes practice. To further complicate matters, resilience is a contested term among gerontological scholars, who debate whether it is something that only certain people possess. Fullen rejects this all-or-nothing view and instead assumes that every person possesses some degree of resilience.

With this core assumption, Fullen and Sean Gorby, a doctoral candidate in counselor education at Ohio State University, piloted a Resilient Aging program, which they believe holds the potential to enhance participants’ perceptions of resilience and wellness. In their pilot study, Fullen and Gorby helped marginalized older adults identify connections between their histories and the ways they had already shown resilience throughout their lives, with the hope that participants could apply this resilience to their present situations.

After Fullen and Gorby introduced the term resilience and allowed the participants to generate their own definitions, the older adults easily identified moments of resilience in their own stories or the lives of others. “Those resilience examples became … counternarratives to the larger societal narratives about aging being only a time of decay and decrement,” Fullen says.

In his prior research, Fullen had noticed that people who are marginalized seemed to possess a hidden reserve of resilience. The pilot study for the Resilient Aging program served as a lightbulb moment for him because he was able to see it in action. “It was a chance for us to better understand the way that people who have been overlooked at various points throughout their lives develop this sort of reserve of resilience that perhaps better equips them to handle some of the challenges associated with aging because this isn’t the first time the deck had been stacked against them,” he explains.

Thus, rather than discussing a marginalized identity such as age only in terms of oppression and deficits, counselors also need to highlight resilience and make it a part of the conversation, says Chan, a past president of the Maryland Counseling Association. “What is so beautiful about working with older adults is that they have such rich narratives [in] their lives. … They have found ways to navigate and make sense of not only their identities but their experiences,” he points out.

Empathizing and reframing clients’ stories

Fullen realizes that using a resilience-based approach requires counselors to walk a tightrope between empathizing with clients’ lived experiences of the difficulties of aging and pointing out an alternative viewpoint. “It’s important not to lose [the] client by jumping too quickly into strength and resilience,” he warns. “[Counselors should] spend some time … building rapport in regard to their grief or their sense of lament related to the aging process but then start to integrate this alternative narrative, alternative conceptualization, that is more strengths oriented or resilience orientated.”

Fullen provides an example of how counselors can navigate this delicate balance in a counseling session. Suppose a client says, “I’m just fed up with this friction between me and my kids. I remember when I was the one calling the shots for them, and now all of a sudden, the tables have turned and I’m not happy about that.” First, the counselor needs to be empathetic, Fullen says. For example, the counselor could say, “Wow, that must be really difficult. It can’t be easy to spend so much of your life being the one who’s providing and now all of a sudden having your kids try to provide for you.” This is not the time to correct the client’s perception of what he or she is going through; instead, the counselor should join the client in understanding how difficult the transition is for the individual, Fullen advises.

As the session unfolds, the counselor can begin a more formal assessment of the client’s perception of how he or she is doing across the wellness domains (emotional, physical, occupational, social, spiritual and intellectual wellness) and how the client views the aging process, which will elicit any age-related bias that the client has internalized, Fullen notes. This is also the time to ask broad questions about resilience, he advises. For example, the counselor could say, “It sounds like things are so challenging right now. I can’t imagine this is the first time that you’ve been through a really challenging situation. So, tell me about how you have shown resilience over the course of your life when it comes to facing really difficult situations like the one you are talking about.”

Fullen notes a broad question that is particularly helpful for counselors to ask when working with marginalized clients: “How have you survived? You’ve been through so much. You continue to go through so much.” This question allows clients to talk about resilience — even if they don’t use that language, Fullen says. Then the counselor can introduce the term resilience by saying, “That is so fascinating to hear about all the ways that you have survived over the years. In my profession, we have a word for that, and the word is resilience. Are you familiar with that concept? What do you make of that concept?” This process subtly introduces a counternarrative to the dominant ageism narrative for both the client and counselor, Fullen says.

If clients begin talking about their history of resilience, then the counselor can incorporate resilience language and help them reframe their stories as resilient ones, Fullen suggests. However, if a client pushes back and says, “I don’t know what resilience has to do with anything,” that indicates the client needs more time to unpack the situation and vent, he says.

The future of gerontological counseling

Despite the obvious need to work with older adults, the counseling profession has slowly de-emphasized gerontology. This has left Fullen to wonder whether gerontology and Medicare reimbursement are priorities for the counseling profession or whether gerontological counseling will survive only as a niche in the future. Currently, Medicare, the federal health care insurance program for people 65 and older, does not cover LPCs.

There seems to be a sense that once Medicare reimbursement for LPCs is achieved, counselors will make gerontological counseling a priority, but that is problematic, Fullen says. He questions whether counselors would be as complacent if an insurance issue hindered their ability to work with another population group, such as children. “We would find ways to innovate. We would find ways to bang that door down,” he asserts.

Fullen points out that although approximately half of older adults’ mental health services are paid for by Medicare, that leaves another 50 percent of mental health care dollars tied to this client population that the counseling profession isn’t tapping into regularly. Counselors need to explore alternative strategies such as private pay, grant opportunities and supplemental insurance, which haven’t received as much attention, he says.

Bailey has heard similar arguments indicating that the counseling profession’s relative lack of interest in serving the older adult population stems from the lack of progress in securing Medicare reimbursement. From her perspective, that makes gerontological counseling a social justice issue. “If we are simply discounting an entire population of people because we can’t make money off of them, that’s a problem that goes well beyond counselor education and CACREP Standards,” she says. “That goes to the heart of the counseling profession.”

“Across the entirety of the profession, there have been inconsistent commitments to the needs of this population,” Fullen asserts. This inconsistency directly affects counseling students, who may struggle to find gerontology-related courses and internships or even counseling professors who are truly knowledgeable in that area.

With the discontinuation of both NBCC’s specialty certification for gerontological counseling and CACREP’s gerontological counseling standards, counselors often must go outside the profession and counseling education departments to receive gerontological training. After developing an interest in working with older adults during her master’s program, Randolph noticed the lack of a gerontology specialization or certification within the counseling profession when she was applying for doctoral programs. To address this, she earned a certificate in gerontology through the continuing education department at the University of Wisconsin–La Crosse.

Bailey is also taking an interdisciplinary approach to gerontological training. She is in the process of finishing a post-baccalaureate certificate in gerontology from the gerontology program at UNCG.

There is a silver lining, however. Namely, the counseling profession already teaches and embraces qualities essential to working with older adults. For instance, counselors focus on using wellness and strength-based approaches, being client oriented and building meaningful relationships. The fact that wellness is vital to the work that counselors do is significant, Fullen says, because wellness can be the antidote against the tendency to view aging through a medicalized lens.

In addition, AADA provides resources and support for counselors who want to work with older adults but do not feel adequately trained. “[AADA’s] overarching goal is to make sure that there are counselors out there who feel prepared to meet the needs of our rapidly aging population,” says Randolph, who serves on AADA’s executive board. In addition, the AADA Older Adult Task Force is focused on expanding and promoting research, advocacy and practice related to older adulthood so that full-time practitioners do not feel alone in working with the older adult population, Fullen says.

Avoiding gray-cial profiling

Earlier this year, Allure magazine made a bold move to stop using the word anti-aging. Acknowledging that language about aging matters, editor-in-chief Michelle Lee challenged readers to consider how the simple act of removing the qualifier “for her age” from a statement such as “She looks great for her age” changes the meaning. Jo Ann Jenkins, CEO of AARP, praised the decision and stated that AARP would follow suit and avoid falling prey to the “anti-aging” trap.

This action highlights the power and danger of ageist language. Counselors steeped in societal ageism and ageist language may incorrectly assume that counseling won’t work with older adult clients, or they may focus only on the physiological aspects of aging. However, as Bailey points out, all people, regardless of age, are still developing. “People can learn throughout the life span. … People can develop new habits and change old habits. … As long as there is air in the lungs, there is potential for change.”

Even though the counseling profession is well-positioned to serve the growing, diverse population of older adults, it often leaves them out of the conversation, committing its own gray-cial profiling. “It’s an open question of whether or not [counselors] will rise to the occasion and start to think in a more sophisticated way about these issues,” Fullen says, “or whether [they’ll] want to continue to keep [their] heads in the sand.”

 

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Lindsey Phillips is a freelance writer and UX content strategist living in Northern Virginia. She has a decade of experience writing on topics such as health, social justice and technology. Contact her at lindseynphillips@gmail.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

 

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

Speaking to the needs of women in counseling

By Bethany Bray January 8, 2018

Rosemarie Scotti Hughes, dean emerita of the School of Psychology and Counseling at Regent University in Virginia, believes that counselor education needs to update the curriculum on the developmental cycle of women and family structure as currently taught in entry-level counseling courses. People are far more diverse in their lifestyle choices than in decades past, she says, but the curriculum hasn’t kept pace.

American women today are getting married and having children much later, on average, than did previous generations. Others are choosing to remain single or raise children on their own or with an unmarried partner. For the first time ever, single adult women outnumber married adult women in the United States.

“The traditional teaching we used to do about life cycles in Counseling 101 or 102 isn’t happening anymore,” Hughes says. “We need to present to students ‘this is what families look like now.’ We need to present a variety of models of what a family can be: same-sex couples, [young adults] living at home after graduating college, couples living together sometimes long years before getting married, having children from multiple partners … single moms who have no intention of marrying.”

Regardless of her life choices, today’s woman is not living in the same world that her mother and grandmothers lived in. In 1960, the median age for a first marriage was 20.3 for women and 22.8 for men in the United States. In 2016, the medians were 27.4 for women and 29.5 for men — roughly a seven-year difference for both genders. In addition, according to the U.S. Centers for Disease Control and Prevention, in recent years, the overall birthrate for American women in their 20s has decreased slightly, whereas the birthrate for women in their 30s has increased.

The social and cultural shifts that Hughes acknowledges are, to use an appropriate pun, married to the issues that female clients bring into the counseling office, from relationships
and family dynamics to career planning and parenting.

These shifts have brought progress in many ways. More and more women are attending college and joining the workforce. At the same time, women continue to struggle with challenges that have plagued the generations before them, such as balancing career and home life and struggling for professional advancement in male-dominated atmospheres.

This reality raises two interrelated questions: What do today’s women need from professional counseling? And how can today’s counselors strive to hit this ever-moving target?

 

 

Diving in

A first step is getting to know the context, culture and full story of the client who is sitting in front of the counselor. Most likely, her experience won’t mirror exactly the U.S. averages for marriage, childbirth, education and other issues.

Recent statistical shifts also differ greatly for women from different backgrounds, especially women of color, notes aretha marbley, an American Counseling Association member and professor of counselor education at Texas Tech University. Women shouldn’t be lumped into one monolithic group, she says, pointing out that the label includes those who are economically disadvantaged, disabled, transgender or otherwise marginalized.

“We need to do a better job of having the voices of all women heard and not just [middle-class female] voices. We’re probably better at that than men, but we’re still not good,” marbley says. “Especially in counseling, don’t make assumptions. Don’t let our voices overshadow those who are marginalized. We really, as counselors, need to do a better job and check our biases at the door — because they’re there.”

Lisa Forbes, an assistant clinical professor in the counseling program at the University of Colorado Denver who also works with clients at an inpatient psychiatric unit at a nearby medical facility, agrees that it is important that counselors not make assumptions. “You can read all the literature on this topic and know everything about women’s rights and equality, but it might not be that way for the woman who is in the room with you. Take each client as their own person,” says Forbes, an ACA member. “First and foremost, take a look at your own beliefs and your own values of stereotypical gender roles. If you’re not constantly trying to challenge those things, you will bring it into the room. … Don’t make assumptions, across the board. Just like any form of multicultural counseling, know the literature, know your personal biases, but get to know your client for who they are and what they need.”

Supporting women clients

Forbes co-presented a session titled “Identity Development of Working Mothers: How to Support Their Mental Health Needs” at ACA’s 2017 Conference & Expo in San Francisco with Margaret Lamar, an assistant professor in the counseling program at Palo Alto University. Women’s issues, especially in the realm of working mothers, is a professional and personal area of interest for Forbes and Lamar, both of who work full time while raising children.

Women frequently can find themselves bumping up against a lose-lose situation, Lamar says. She explains that a woman who works often gets judged as being a bad mother because she doesn’t see her children as much as stay-at-home moms see their kids. At the same time, her workplace supervisors or co-workers might feel she is a liability because she still has to manage the pull of children and family distractions. Pew Research Center data indicate that mothers now spend more hours per week engaged in child care than women did in 1965, Lamar notes.

“There is an expectation that moms should be more present as mothers, but at the same time we’re seeing more and more women in the workforce,” says Lamar, a licensed professional counselor (LPC) and ACA member. “We see women having more anxiety, more depression and feeling overwhelmed. When women are trying to juggle all of these things, the first thing to go is self-care and a focus on relationships. They go into survival mode.”

“These are things that are showing up in our counseling sessions,” she continues, “and we need to be mindful of the language we’re using [and] how we’re pathologizing women. Be aware of that oppressive social context so we are not blaming women. Talk with your clients about [how] they are living in a climate where these expectations are commonplace and it affects mental health.”

Hughes, a recently retired LPC and licensed marriage and family therapist (LMFT) in Virginia, says she often saw female clients who had children later in life and struggled with perfectionism. They often kept their children involved in an endless string of activities, from dance classes and sports to music lessons and Scouts, and then planned extravagant birthday parties and other social activities, Hughes observes.

“They’re adding so much stress to their lives, all of this on top of working,” says Hughes, who wrote the chapter on feminist theory in the ACA Encyclopedia of Counseling. “They keep the kids involved in so many things because they think the kids need all these things for them to be a good mother. I don’t see that they can accept the concept of being a ‘good enough’ mother. … Thinking they can put all of these things into a 24-hour day is fairly unrealistic. You can work and raise your family, but you can’t be supermom. We were never meant to be supermom.”

Hughes says counselors can work with these clients to challenge the irrational thinking that spurs perfectionism and help them focus on what matters most: their relationship with their children.

This “intensive mothering expectation” can lead to self-esteem and identity issues, anxiety, depression and other mental health struggles, Forbes says. The concept, coined in the mid-1990s in the book The Cultural Contradictions of Motherhood by Sharon Hays, an assistant professor of sociology and women’s studies at the University of Virginia, originates with the stereotypical ideal of the 1950s housewife: The woman keeps the household running while bearing responsibility for the majority of household chores and child-rearing tasks.

Decades later, that expectation — whether stated overtly or in more subtle ways — is still going strong, Forbes says. “It puts women in a tough spot, and that’s all wrapped up in our identity development. It’s the idea of a mom who is always involved, takes the kids to their activities and makes kale smoothies every day — being everything for everyone — and it’s really an impossible feat. That’s kind of what we judge women by, and I think it’s unfortunate that we can’t bend a little bit on that.”

Women can even project these expectations onto other women, intentionally or unintentionally, through social media posts and in-person comments, further perpetuating the problem. Forbes has seen this play out in her own life. She is the mother to a 4-year-old and a 2-year-old, and her husband travels often for work.

“I personally struggle a lot with balancing all of these roles and the expectations that moms are put under,” she says. “If I spend an hour away from my kids, I am judged, but if my partner spends an extra hour with the kids, he is patted on the back.”

“If we [practitioners] don’t challenge our own beliefs on this, we will inadvertently bring this into the counseling session,” she adds.

The importance of language

Most of all, counselors must be mindful of the language they use with female clients and check their own assumptions, Lamar says. For example, a counselor working with a female client who is feeling anxious and overwhelmed may initially assume that the woman simply needs to take on less, delegate responsibilities to a partner or ask for help. Although well-meaning, these suggestions carry the implication that the woman is responsible for everything and should be the one to give the responsibility away, Lamar says.

Instead, the counselor might coach the client to negotiate responsibilities with a partner and make a plan, from arranging for childcare to doing the grocery shopping. “It’s really a … shift in our thinking of how to approach that [with a client]. It needs to be both partners coming at this together and negotiating on equal footing,” Lamar says. “It may not be as simple as having trouble setting boundaries. She is under pressure to take on all these pieces in order to feel like she’s a good mom or a good employee. Pay attention to how we acknowledge that instead of placing the responsibility on the woman.”

Similarly, a counselor working with a new mother who is getting ready to return to work should think twice about asking her whether she is ready or if she can handle it, Forbes says. Those kinds of questions assume that it is all up to her. The underlying message is, “You’re the mom. You should stay home,” Forbes observes. Likewise, questions such as, “How are you going to balance everything?” send the message that the client has to balance everything, she
adds. Instead, Forbes suggests that counselors turn their questions to focus on how the mother can advocate for herself to find support and equality at home and at work.

Cassie Owens, an LPC in private practice in Dunwoody, Georgia, cautions that counselors shouldn’t lump their female clients into specific categories — new mother, working professional, single mother — and make related assumptions. “There’s so many different chapters to a woman’s life, and most women wear more than one hat. Be really mindful when asking questions and doing assessments, and don’t make assumptions … based on that first, initial impression or intake session,” says Owens, who specializes in maternal mental health and works exclusively with female clients.

Forbes also focuses on the importance of getting to know the client and her situation. “Listen to a client’s language. Is she wanting help, or is she not sure how to ask? … What changes in her life does she want to make, and what can she advocate for?” counsels Forbes. “Always check in to brainstorm ideas. … Have them make a list and pick one [area to focus on]. What’s the worst-case scenario of an outcome, and what’s the best-case scenario? She knows better than you how things might turn out.”

The same wisdom applies when counseling clients about issues in the workplace, Lamar says. A counselor should not coach a female client to speak up when she is being overlooked professionally without considering her circumstances and professional context. “You should stand up for yourself” is often impractical advice for a number of reasons, including the risk of repercussions, Lamar explains.

“People still underestimate the pressures that women feel in the workplace. I work in academia and mental health, two [professions] that are supposed to be more ‘aware,’ and I have had people take credit for ideas that I’ve had or talk over me in meetings,” Lamar says. “I had a male student explain to me why some [of my] research was wrong. It kind of baffles me. There’s just so many women who experience these kinds of things — microaggressions, victim blaming and, recently, sexual harassment. These are things that women experience all the time to varying degrees.”

The widespread nature of these experiences has made headlines recently as more women have begun coming forward to report cases of sexual harassment involving major figures in
the worlds of politics, entertainment, news media and other professions. We have also repeatedly witnessed examples of why women often choose not to report wrongdoing out of a fear of making waves and the victim blaming that can follow.

Identity and resetting the narrative

It may be useful for counselors to weigh protective factors in female clients’ lives against their risk factors, Forbes says. For instance, counselors might look for areas of life where these clients can strengthen their network of support socially, professionally or therapeutically, such as through local women’s or mothers’ groups, social clubs, nonprofit organizations or church groups.

Finding a “tribe” of people a client can relate to is helpful in combating the feelings of isolation that often accompany many of the issues with which women struggle, especially postpartum depression, Owens says. Online groups can also be a source of support for new mothers or women in different stages of life, says Owens, the vice president of the Georgia chapter of Postpartum Support International. Owens had one client who was a member of a Facebook group for local moms. She invited others to join her for a walk, posting the date, time and location of where to meet. Several women came, allowing her to meet some new people with the shared experience of motherhood.

“That takes a lot of courage, but she really wanted to meet people in her neighborhood,” Owens says. “Also know of support groups that other therapists are running, and know and work with other practitioners in your area. A counselor can help a client navigate them and just [let them] know that these kinds of things exist.”

Counselors can also help support female clients by exploring issues of identity. Often, a woman’s identity is tied to expectations that she has internalized, Forbes says. Counselors can help clients dismantle unhealthy expectations — for example, the mother who does it all — and become aware of how unrealistic they are.

Identity can also be central for women facing transitions, such as a client having a baby in her late 30s after a decade of building a career. This can be a “shock to the system,” Forbes says, because it upsets the equilibrium the client previously felt in her identity.

“Talk the client through her new identity. Being a mother is such a strong identity for a woman, but how can we add that to your existing identity [rather than replacing it]?” asks Forbes. The counselor needs to meet the client where she is. Instead of saying, “This will change everything,” help her to make a plan and rely on a support system, Forbes says.

Owens agrees. “If they’ve had a career and decide to stay home with a baby, it’s a huge change in identity, a loss of self and [can be] a loss of self-worth. Or, it’s the juggling act of going back to work and balancing life. ‘How am I going to be a good mother and employee and [still] take care of myself?’”

In addition to focusing on protective factors, Forbes finds that narrative, feminist and relational-cultural therapies are often helpful when working with female clients. Bibliotherapy can also be used to normalize the expectations and pressures that female clients may be feeling. Forbes recommends anthropologist Solveig Brown’s book All on One Plate: Cultural Expectations on American Mothers to learn more about the intensive mothering concept and its unrealistic expectations.

Helping clients recognize the unrealistic expectations that society often places on women is important, regardless of the theory or method a counselor uses. “There’s so much value in externalizing the problem from the woman. Patterns can be so ingrained that you don’t challenge them, but if you can name them and externalize them, it can be liberating,” Forbes says. “It’s really empowering for women to get to that place that ‘I am not my symptoms; my symptoms are the result of my experience.’”

For example, a female client may be struggling with the decision to take a promotion at work because she feels her children need her more. “Go deeper. Ask the client, ‘What does that mean for you when you have that thought?’ Is it about guilt? If she feels she should be at home with her children, that guilt could turn into low self-worth and feelings of ‘I’m not a good mom,’” Forbes says.

“I would externalize that guilt that she has,” Forbes continues. “She feels like it’s her fault that she has two different roles — mother and employee — and that guilt comes from within. Talk about where that guilt [actually] comes from: greater society. Challenging those societal expectations can help.”

Similarly, Forbes suggests, feelings can be externalized through a version of the empty chair technique typically associated with Gestalt therapy. The client is invited to put her guilt in an empty chair so that she can visualize it, feel it and talk to it. That takes the blame away from the client and helps her realize that “this is not you; it’s your experience of expectations and unfair stereotypes,” Forbes explains.

“Tell [the client], ‘You are not a failure. You live within a context of a culture, within a family, and all of those things affect your self-image and your mental health,’” she says. “They can rewrite their own story on how it works for them, not the way they’ve been told it should be.”

The long road to progress

Although cultural shifts mean that more women are advancing in their careers and living independently, the struggle for progress is far from over. The counselors interviewed for this article agreed that the conversation needs to be ongoing.

Women still shoulder the burden of unpaid maternity leave, child care costs that can be staggering and a pervasive wage gap between them and their male counterparts that is even more pronounced for women of color. There is substantial potential, Lamar notes, for counselors to strengthen their role as client advocates, especially when it comes to policy changes surrounding family leave, child care and other social issues.

“We’re not in a place, as a group of women, to say we’re all done [making progress] now,” says marbley, an LPC supervisor and leader of the ACA Women’s Interest Network. “We need to continue to advocate for those who don’t have the power or ability to do so. We’re not free yet. We’re not ready to say it’s all equal. We can still do better, and if we [women] empower each other, we can help. At the end of the day, it’s not bad. We just have more work to do.”

Hughes was the first female academic dean at Regent before she retired from counselor education in 2009. She notes that throughout her tenure, most of her colleagues and subordinates were male. Likewise, marbley says that in her experience, promotion and tenure remain a struggle for women in counselor education. She also notes that many of the conferences and professional events that young women counselors attend are led by males.

Counseling is a relatively young profession. Perhaps, Hughes says, the work of recognizing the subtleties and needs of women in counseling can be attributed to the profession’s growing pains. “This is all part of counseling’s struggle with identity,” she says. “I’m still not sure if counselors know who we are.”

 

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Statistics snapshot: Women in America

  • On average, women make 80 cents for every dollar earned by a man, a gender wage gap of 20 percent (full-time, year-round employees, as of 2015).

Source: Institute for Women’s Policy Research bit.ly/2leGr6t

  • This past fall, the majority of U.S. college and university students were female — an estimated 11.5 million women compared with 8.9 million men.

Source: National Center for Education Statistics bit.ly/1DLO7Ux

  • Women who are single or living with a nonmarital partner account for 4 out of 10 U.S. births. Less than half of children (46 percent) are living in what has previously been considered a “traditional” household: a family with two married parents in their first marriage.

Source: Pew Research Center pewrsr.ch/1OypOcD

  • It was reported this past year that the mean age at which American women have their first child is 28 years old. In 2014, the mean was 26 years old; in 2000, it was 24; and in 1970, it was 21.

Source: Centers for Disease Control and Prevention bit.ly/2AbMUJQ

  • Between 2007 and 2017, the share of U.S. adults living without a spouse or partner increased from 39 percent to 42 percent.

Source: Pew Research Center pewrsr.ch/2jsZuu5

  • In 2012, 42 million Americans, or 1 out of 5 adults ages 25 and older, had never been married. In 1960, this statistic was roughly 1 in 10.

Source: Pew Research Center pewrsr.ch/1qu8b10

 

 

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To contact the counselors interviewed in this article, email:

 

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

Letters to the editor: ct@counseling.org

 

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