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Counselors Audience

Counseling people who stutter

By Chad M. Yates, Karissa Colbrunn and Dan Hudock April 11, 2018

Kyle hears the drone of the elevator music playing behind the bland voice that states, “All calls are important to us. Thank you for your patience. A customer service representative will be with you in just a moment.” Kyle knows the message well because he has been on hold for nearly 15 minutes. While waiting, Kyle practices in his head the message he needs to state: “Hello, my name is Kyle, and I need to schedule a shuttle ride to and from the airport.”

Suddenly, a crackling voice replaces the music. “Hello, thank you for calling OK Shuttle. How can I assist you?”

Kyle feels his throat tighten and his chest begin to seize. “Hello, my name is Kyyyyyy, my name is Kyyyyyyy, Kyyyy.”

“Sir, are you there? Sir, are you there?” insists the customer service rep.

Kyle continues: “Hello, my name is Kyyyyle. I need to schedddddd … I need to schedddddd, scheddddd.”

“Sorry, sir,” the voice on the other line says. “We have a poor connection. Please call back again when your service is more reliable.”

The sound of the click thunders in Kyle’s ear as a tight-pitched squeal replaces the silence. Kyle looks down at his feet, too afraid to pick them up and move. He feels frozen in anger, disgust and helplessness. Fear precludes the idea of calling back again.

This experience is all too common for people who stutter (PWS). For these individuals, the experience of communication, which many of us take for granted, becomes a blockade that stands between connection, understanding and the navigation of one’s world.

Experts in the field of speech-language pathology define stuttering as a communication disorder involving disruptions, or disfluencies, in an individual’s speech. The cause of stuttering is typically thought to be a neurological condition that interferes with the production of speech. Although many children spontaneously recover from stuttering, for approximately 3 million U.S. adults (about 1 percent of the population), stuttering is chronic and has no cure. Despite this, there are ways to manage stuttering in both the behavioral sense (how much the person stutters) and the psychological sense (how much stuttering impacts the person’s life).

Situations such as the one that Kyle experienced can happen almost daily for PWS. The pain of these experiences often leads these individuals to isolate themselves from the things they love to do because the risk of communicating can feel as if it outweighs the benefits of living the life they want to live. Peer reactions to unusual speaking patterns can begin as early as age 4. These reactions persist and increase throughout adolescence, which can negatively affect many facets of life, including social relationships, emotional well-being and academic performance, for PWS. Adults who stutter have scored significantly lower in questionnaires regarding quality of life, specifically in regard to vitality, social functioning, emotional role functioning and mental health. Although various studies show that counseling is indicated with this population, many speech-language pathologists are not trained in counseling or do not feel comfortable with their counseling skills and abilities.

Interprofessional collaborations between speech-language pathologists and counselors can be considered best practice for helping PWS and other individuals with common communication disorders. Idaho State University’s counseling and speech-language pathology departments are involved in a unique relationship in which they are training both speech-pathology interns and counseling interns to work side by side to treat PWS. This treatment is provided through the university’s Northwest Center for Fluency Disorders Interprofessional Intensive Stuttering Clinic (NWCFD-IISC), which offers a two-week clinic for adolescents and adults who stutter.

The clinic is the first of its kind in which speech-language pathologists and counseling interns work together to treat the holistic needs of clients who stutter through acceptance and commitment therapy (ACT), a mindfulness-based mental health approach. We (the authors of this article) have conducted the clinic over four consecutive years. Through this experience, we feel that we can share recommendations for counselors working with PWS and with other clients who present with communication disorders. Additionally, we have observed key ingredients for interprofessional collaboration and can speak to strategies to build effective interprofessional teams.

Recommendations for counselors

To be effective working with PWS, counselors need to address the misconceptions they have about stuttering. Consulting resources, such as the National Stuttering Association and the Stuttering Foundation, that are supported by PWS can help counselors to debunk common myths associated with this population.

One common myth is that stress causes a person to stutter. Another myth is that taking deep breaths before one speaks can eliminate stuttering. We have heard countless “cures” for stuttering from the general public. These include placing spices under one’s tongue, receiving acupuncture and sitting or standing with the correct posture. These erroneous cures can be insulting and demeaning to PWS. At best, it is frustrating for PWS to hear these ideas repeated over and over again. Counselors should be knowledgeable about the lack of support for these types of cures while being able to point out to clients resources on effective treatments.

For PWS, reactions from listeners often can be painful. As PWS become more aware of their stuttering and encounter negative listener reactions to their disfluencies, they may develop negative emotions toward communication situations and begin to avoid speaking. The shame and guilt that PWS often feel for stuttering can lead to fear, anxiety and tension in relation to communication, as well as decreased self-confidence. PWS may develop secondary behaviors that they employ in hopes of alleviating their stuttering. These secondary behaviors might include avoiding eye contact, avoiding speaking to people in positions of authority and avoiding certain words that they anticipate stuttering. Being aware of this, it is important for counselors to understand the role that positive regard, expressed behaviorally through continuous eye contact or not averting their glance when PWS speak, can have on these individuals.

Working effectively with PWS also involves using positive and respectful communication practices. During conversations, time pressure can be present when PWS take longer to communicate. This can sometimes lead to one party attempting to finish the other’s sentences. To PWS, this behavior can suggest that their communication of ideas may not be as important as the other speaker’s time.

Finishing a person’s sentences is often done in reaction to uncomfortable feelings associated with the time pressure of communication. Counselors should be aware of when they are experiencing these feelings. They should continue to allow their clients who stutter to finish what they wish to say regardless of time pressure and regardless of whether these clients are having blocks (when sound or air is stopped in the lungs, throat or mouth/lips/tongue), breaking off speech or having repetitions (repeating a sound, syllable or word more than once or twice).

The final recommendation involves the use of person-first language. Often, PWS call themselves “stutterers.” Reframing the language to say a “person who stutters” can reduce the stigma that surrounds the word “stutterer.” This action also treats the person as an individual. During the NWCFD-IISC, we empower PWS and work to mitigate stigma by reinforcing the idea that what a person says is more valuable and important than the way he or she says it. We also affirm that all individuals deserve to communicate their thoughts and ideas.

Recommendations for interprofessional teams

Interprofessional teams can be difficult to start and maintain in practice. Professional training often maintains solo practice as its modality, adding topics related to interprofessional collaboration as elective practice. We have used the stuttering clinic as a way to train counseling and speech-language interns in interprofessional practice and application.

We have observed that to effectively build these teams, it is essential to train our interns on the respective scopes of clinical practice, professional roles and clinical responsibilities of each other’s professions. We also train our students on how to work in teams, how to build relationships based on open communication and respect, and how to understand and use team dynamics that occur during practice. Finally, we reinforce the shared values of both professions — that the well-being of the client is paramount to the purpose of the team.

We have observed that interns typically begin collaborations with thicker boundaries of professional practice and rigid time sharing when interacting with clients. However, after the pair begin to find comfort and understanding of each other’s professional roles, these boundaries begin to wane. Time sharing becomes much more dynamic and less rigid. When intern pairings are working effectively, we see the pair begin to assist each other in their roles and to plan out how they can work together to assist the client during the next session.

To facilitate the interns working together, we teach them specific strategies that are unique to each profession. For example, the speech-language interns learn how to use basic listening skills and practice these skills with the help of their counseling partners. Speech-language interns also learn the foundations of counseling interventions. Specific to the NWCFD-IISC, the interns learn the foundations of ACT. All interns are also taught the practice of meditation and mindful practice, and the principles of acceptance, thought defusion and emotional expansion. Counseling interns learn the foundations of speech-language pathology interventions. Specific to the NWCFD-IISC, they learn about how stuttering occurs, how to assess for stuttering and the social and emotional impacts of stuttering.

All interns in the clinic engage in pseudo-stuttering (fake stuttering) in public and use speech-modification techniques with all clinic participants and the public. Pseudo-stuttering can be used as a therapeutic strategy for PWS to increase acceptance and openness with their stuttering and to increase self-confidence. When the clinic interns pseudo-stuttered and used speech-modification techniques with NWCFD-IISC clients in public, the clients reported that these experiences strengthened the client-clinician relationship.

Our recommendation to counselors and speech-language pathologists who desire to develop collaborative teams is to be intentional about building a professional relationship on the grounds of respect and open communication. The team members should take time to learn about one another’s professions, roles and clinical responsibilities. We have observed during the training of our interns that speech-language pathologists are often focused on outcomes and data collection, whereas counselors are often more focused on process elements and the clinical relationship. It is essential to see both sides of the team as contributing to the overall impact in a unique way. The team members will work to support one another’s strengths and weaknesses.

Counseling interventions

The NWCFD-IISC uses an ACT framework. ACT was chosen because it provides a strengths- and skills-based approach grounded in mindfulness and psychological flexibility. ACT explores human suffering as it relates to psychological inflexibility. Using this framework, PWS learn to more fully focus on the present moment, become more accepting of their thoughts and feelings, and take steps toward acting in alliance with their personal values.

Several studies have supported positive results regarding the efficacy of ACT when applied to stuttering. In addition to this supported efficacy, we think that ACT closely aligns with the philosophy of the NWCFD-IISC. Our philosophy of treatment involves clients and students taking a team approach to understand, accept and effectively manage thoughts, emotions and behaviors related to stuttering. This is accomplished through generalized experiential activities, group education and discussion, and individual and group counseling.

ACT can be understood through the six guiding principles on the ACT hexaflex. These six principles are acceptance, thought defusion, mindfulness, self as context, values and committed action. Investigating how each principle applies, we can begin to understand the process of counseling PWS through an ACT lens.

1) Mindfulness: Clients who stutter often avoid the present moment by judgmentally reviewing the past or worrying about the future. Clinicians can help PWS to connect with the present moment through the use of meditation and mindfulness activities. Encouraging mindful practices can be a goal to incorporate in counseling.

2) Acceptance: PWS often feel like they have no control over their stuttering. Regardless of what they do, a stuttering moment may or may not arise. In these moments, PWS can choose to talk, choose to stutter openly and choose to acknowledge all the thoughts and emotions related to stuttering. Clinicians can help PWS explore acceptance of their thoughts and feelings. PWS do not need to like the thoughts or emotions they experience or enjoy stuttering. However, they can experience their thoughts or emotions as they surface without judgment.

3) Thought defusion: PWS have a tendency to overidentify with their thoughts or feelings, enabling these thoughts and feelings to become mental truths that cause inflexibility within the thought process. PWS may attempt to mentally avoid stuttering or become overwhelmed trying to control their speech. Additionally, PWS may feel certain that other people will reject or harshly criticize them, thus causing them to avoid social contact.

Clinicians can help PWS to explore and express all thoughts — helpful and unhelpful — about their stuttering. By unhooking from the thought or emotion, PWS can experience more psychological flexibility in relation to the context that the thought or emotion is occurring within.

4) Self as context: Individuals often associate with expressions in the form of labels, such as “I am smart” or “I am dumb.” These labels relate to content, not context. Individuals may define themselves in terms of content instead of context to fuse with thoughts and emotions that may be either known or unknown. PWS use self-as-content behaviors to avoid facing the reality of stuttering. PWS may think, “I stutter. That’s all I do. Because of my stuttering, I do poorly in school and never meet new people.”

Clinicians should explore with PWS how these thoughts about self are related either to content or context. Reinforcing flexibility in self-identity is key because it allows PWS to adapt more flexibly to novel situations.

5) Defining values: As described by Jason Luoma, Steven Hayes and Robyn Walser, in ACT, values are defined as “constructed, global, desired and chosen life directions” that can be expressed as adverbs or verbs. When exploring values with PWS, the notion of choice is important to discuss. Choice connotes the flexibility and autonomy they possess in defining what guides their behaviors or life direction.

A common values activity involves the “eulogy exercise.” During this activity, PWS visualize what a close friend would say at their funeral. Clinicians might even direct PWS to write down the values that were expressed during the eulogy: “He was a kind person” or “She was a caring friend” or “He was a compassionate individual.” Clinicians can then discuss these values with PWS and explore how these values are currently manifested and how they can become lost. Building awareness of what values are important in a person’s life can encourage these clients to persist through the difficult times they face.

6) Committed actions: ACT explores the concept of choice in alignment with values-based goals. When clients feel ready to initiate steps either within or outside of counseling, exploration of these committed actions in the counseling session is warranted. For PWS, committed actions could be used by encouraging challenging stuttering situations. For example, PWS may choose to take action directed at speaking situations during dating, during novel social interactions or within work settings. Committed action is the stage of counseling that encourages the synthesis of the tools within the complete hexaflex. PWS learn to engage in a way that is adaptive and flexible to their external and internal worlds.

Summary

Counseling PWS can be a rich and rewarding experience. Through our work in the NWCFD-IISC, we have built lasting connections with individuals in the stuttering community and learned how to form strong interprofessional teams that enhanced our understanding of two professions. In working with PWS, understanding the specific population concerns is key to effective treatment. Additionally, collaboration with professionals in the speech-pathology discipline can further enhance treatment experiences for PWS and for all professionals engaged in the collaboration.

 

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Chad M. Yates is a licensed professional counselor and an assistant professor in the Idaho State University (ISU) Department of Counseling. He has served as the mental health coordinator for the Northwest Center for Fluency Disorders at ISU for several years. He helped to develop the acceptance and commitment therapy (ACT) manuals and procedures for clients and clinicians at the clinic and supervises the counselors providing ACT. Contact him at yatechad@isu.edu.

Karissa Colbrunn is a school-based speech-language pathologist in Pocatello, Idaho. She is passionate about merging the values of the stuttering community with the field of speech-language pathology.

Dan Hudock is an associate professor at ISU. As a person who stutters, he is passionate about helping those with fluency disorders. One aspect of his research involves exploring effective collaborations between speech-language pathologists and mental health professionals for the treatment of people who stutter. He is the director of the Northwest Center for Fluency Disorders. For information about research, clinical or support opportunities, visit northwestfluency.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 people in the performing arts

By Bill Harrison April 10, 2018

Actors, dancers, musicians and other performers are vulnerable to a variety of challenges and clinical issues that are unique to those who choose to make their living using their creative talents and skills. Although artists are people just like the rest of our clients, I believe it is important for counselors to have a framework for conceptualizing the idiosyncratic personal, cultural and professional contexts in which many performers live. As Linda H. Hamilton says in her excellent book The Person Behind the Mask: A Guide to Performing Arts Psychology, “Catering to the special needs of performers is important because of the unique psychological, biological and social stressors related to this vocation.”

My knowledge about the performing arts community comes from many years of personal experience. I became a counselor after working as a professional musician and an occasional actor since the late 1970s. I have played, toured and recorded as a jazz and pop musician. I have also performed in theatrical pit orchestras for many national tours and local productions here in Chicago. I am trained in the acting methods of Sanford Meisner and have worked onstage and appeared in independent films and commercials.

As a counselor, I have been fortunate to work with a diverse cross section of artists, combining my counseling training with my intimate knowledge of the music and theater business. Even so, my clients have been my best teachers. In my view, performers are an underserved clinical population worthy of serious consideration by more counselors. There are, after all, many more actors, dancers and musicians who need counseling than there are clinicians who used to be performers.

Life onstage is analogous in many ways to life as an athlete. The performing arts and sports are inherently stressful professions because of the high expectations of both the audience and the people who have the power to hire and fire. Success in both fields depends on a lifetime of training and constant vigilance, both in maintaining awareness of one’s self in relation to the work and in maintaining one’s skills. Although a great deal of research and attention have been focused on sports physiology and psychology, relatively little clinical attention has been paid to performing artists. The few books available on the subject are largely outdated, and the scholarly literature is scant. Hopefully, this situation will improve in the near future.

What are the life factors that distinguish performers from other individuals who make their way to our counseling offices? It is useful to discuss this population using several contexts: developmental, career, performance-related and societal. Each context has both case conceptualization and treatment factors.

Developmental considerations

Many performers began their training as young children. Some can barely remember when they began to exhibit signs of talent. They may have been singled out as “special” among their siblings or classmates if they showed an aptitude for singing, playing an instrument or dancing.

Counselors should pay particular attention to these clients’ attachment issues with both parents and teachers. Were caregivers supportive or resistant to their child’s talent? Did the client feel encouraged, pushed or dismissed in relation to his or her natural abilities? Was the child considered a prodigy? Did the parental emphasis on performing distract from focusing on social and emotional development?

Many artistically gifted children display a poise that is easily mistaken for emotional maturity. As a result, the normal childhood needs often are either ignored or derided as “childish.” The prodigy label often comes with potentially unhealthy complications, given that 3- and 4-year-olds are incapable of making life-altering decisions for themselves.

Early teachers of these children may have been supportive and loving or harsh and critical. For many young performers, competition for coveted positions can be intense. Children are keenly aware of the talent/skill hierarchies. Were they chosen for the best parts or overlooked? Did they land spots as lead actors in plays, prima donnas in the opera, first-chair players in the orchestra or principal dancers in the ballet? If they are relegated to secondary roles, some children feel that they have somehow failed. This can have repercussions when similar situations occur in their adult lives.

All of these factors play major roles in the personality development of performers. Young children who demonstrate a natural affinity for a certain area of performance are vulnerable to overidentifying with their talent. Counselors need to be aware that a client’s degree of healthy narcissism may be directly linked to his or her perceived level of artistic ability. Besides being treated as special and having to compete, young performers can become socially isolated and lead a very unbalanced life that consists almost exclusively of developing their artistic gifts at the expense of emotional and interpersonal growth. This can become problematic later in life, if and when the client realizes that there is more to life than performing. And in relationships, there is a risk that performance can substitute for genuine intimacy.

Career considerations

A performing artist’s career trajectory is often short and always unpredictable. Unlike in many other professions, there is no clear-cut path to professional success or advancement when you act, play, sing or dance for a living. No amount of natural talent or advanced training can predict success with any reliability. Talent or skill may not matter nearly as much as happenstance, luck or physical appearance (principally for actors and dancers).

Although things seem to be changing incrementally, considerable racial and gender bias still exist in casting. With the dearth of acting and dancing parts for women over 35, it is difficult for women performers to sustain a career much past that age. Issues related to stereotyping and appearance aren’t that much easier for men.

In addition, the ability to earn a living is quite limited for most performers. For example, in 2008, The New York Times reported that only 5 percent of Screen Actors Guild-American Federation of Television and Radio Artists members earned at least $75,000 annually. Actors’ Equity Association, the union representing the world of live theatrical performance, reported that during the 2013-2014 theater season, only 9 percent of its members earned more than $50,000. On average, just over 13 percent of unionized actors were working in any given week that year; their median annual income was $7,463. According to HuffPost, in 2012, the Future of Music Coalition estimated that full-time musicians earn an average of about $34,000 per year.

Low income is just one stressor in the life of most performing artists. A 2015 Australian study, “Working in the Entertainment Industry,” reported strong correlative evidence that underemployment, employment uncertainty, unregulated working conditions and the societal devaluation of artistic work often precede the onset of emotional and cognitive impairment. The large majority of actors, dancers and musicians have to secure secondary employment to make ends meet. The number of performers who continue working past age 30 declines precipitously. The researchers interpreted this to mean that as people begin to focus on their non-arts-related life (marriage, family, home ownership, financial stability), they are more likely to give up on their artistic ambitions and “get a real job.”

The authors of the study concluded “that there is ample evidence to support the assertion that the work environment of the creative person is … fraught with difficult and challenging circumstances. These include performance anxiety, work overload … career anxiety, a lack of career mobility, irregular working hours, high rates of injury, low financial rewards, [having to maintain] high standards of performance, financial insecurity and sporadic work.”

It is crucial for counselors to recognize these professional limitations for people in the performing arts and to keep them in mind as we would for any kind of cultural context.

Performance-related considerations

People in show business expose themselves to some of the most physically and psychologically stressful conditions on an everyday basis. Auditioning, rehearsing and performing require intense concentration, focused energy, strong self-confidence and years of preparatory work. Work hours can be extremely demanding. Knowing that a hundred people are waiting in line behind you to take your job if you falter is nerve-wracking. For these reasons, performers are at risk for anxiety, loss of motivation, difficulty concentrating, burnout, physical injuries, low self-esteem, poor emotional regulation, sleep disruption and crises of confidence and identity.

Because most performers work as members of an ensemble, there can be difficulties with group dynamics or conflicts with co-workers with whom they may be living or traveling. In addition, the “instant intimacy” that can develop between members of a cast can sometimes pose challenges to the stability of relationships outside of the ensemble.

Anxiety and depression are common complaints among performers, just as they are for the general population. However, recent research suggests that the prevalence of both mood disorders is much higher among artists. The Australian study found evidence that performers are 10 times more likely to suffer from anxiety and five times more prone to depression. Likewise, they are three times more likely to experience sleep disorders. Performing artists have higher rates of suicidal ideation, planning and attempts; their abuse of alcohol and other substances is also significantly greater when compared with the rest of the population.

One of the most ominous findings of the Australian researchers was pointed out to me in a personal communication from the lead author of the study, Julie van den Eynde. She wrote that the researchers found “a solid link with suicidal behavior … to depression, anxiety and lack of social support. There was no link to alcohol and drug use. There were no differences in gender or age. These findings run counter to the normal population, as suicide behaviour is different for age and gender and is linked to alcohol and drug use. This means that creative artists and performers are a different and separate group.”

In other words, this population is at higher risk for suicidal behaviors regardless of other factors such as age, gender and substance abuse.

Societal considerations

Despite the performing arts contributing so much to the enjoyment and enrichment of people’s lives, performers are often treated as if their work has remarkably little value (with the exception of the tiny subgroup of the most popular and famous individuals). Due to the nature and intensity of the commitment that a life in the arts requires, performers tend to identify very strongly with their work. If an artist’s work is subject to the uncertainty and devaluation described in the study, then that person’s identity is at risk.

As noted earlier, earning a living wage from performing is difficult for the majority of artists. As is the case for any client whose income is below average, artists are more vulnerable to the societal biases against people who aren’t comfortably middle class, don’t have health insurance or lack a high credit score.

Art often serves society by expressing cutting-edge ideas, including criticism of the status quo. This artistic purpose is often undertaken by people who are most impacted by racism, sexism, genderism, ableism, etc., and who make up a substantial portion of the artistic community. Societal marginalization can contribute significantly to myriad therapeutic issues. Although performing can serve as an emotional outlet for minority populations, the extent to which their ability to express themselves publicly improves their mental health will vary from person to person.

Clinical considerations

It almost goes without saying that performance anxiety (aka stage fright) is often the issue that brings people in show business into the counseling office. Many performers experience stage fright before every show. Famous sufferers include Laurence Olivier, Scarlett Johansson, Ella Fitzgerald, Adele, Pablo Casals, Mikhail Baryshnikov, Vladimir Horowitz and Renee Fleming.

But for many artists, auditions provoke the most anxiety. Auditions present a perfect storm of conditions almost guaranteed to induce performance anxiety in even the most seasoned artists. There is a saying among actors: “Auditioning is your vocation; working is your vacation.” Anxiety before and during auditions arises from the belief that a negative judgment of one’s performance equates with humiliation, embarrassment or personal rejection. Actors face this kind of scrutiny each time they read for a role; rejection is a normal facet of life for them.

Perfectionism is another anxiety-related malady that may surface in counseling sessions with performers. It may present in conjunction with excessive procrastination, practice or rehearsal avoidance, guilt, anger, self-criticism or blaming others, eating disorders and suicidal ideation. As pointed out in Robert H. Woody’s 2015 Psychology Today blog post titled “Perfectionism: Benefit or detriment to performers?” some performers exhibit narcissistic traits that may be associated with perfectionism.

Depression is precipitated in this population for many of the same reasons that anyone else might experience depression. However, some performance-related triggers for depression include:

  • Being overlooked for an audition
  • Despairing over not getting a coveted part
  • Sustaining a career-threatening injury
  • Being confronted with an inability to start (or finish) a long-dreamed-of creative project
  • Being forced to choose between one’s performing career and the demands of one’s romantic or familial life
  • Contemplating leaving a profession that has defined one’s identity

Although certain myths persist about the prevalence and glorification of drug use among performers, substance abuse is a real problem for many actors, dancers and musicians. The combination of high stress, employment uncertainty, low income, inaccessible health care and easy availability of alcohol and other mood-altering substances results in a higher-than-average probability that these clients may be affected by substance abuse and addiction. During intake, counselors should assess for drug and alcohol use, particularly with clients who present with anxiety or depression.

Social isolation, chiefly among musicians, is another common issue. Young people with musical talent, especially those singled out as prodigies, must spend many hours a day practicing their craft. In some cases, this single-minded approach, though perhaps necessary for achieving virtuosity, can lead to social anxiety, poorly developed social skills and difficulty forming intimate relationships. Adult performers who present with social anxiety may have long-established patterns of self-isolation resulting from intensive practice regimens begun in childhood. For a deeper understanding of these issues, I highly recommend Andrew Solomon’s chapter on prodigies in Far From the Tree: Parents, Children and the Search for Identity.

Many performers, and artists more generally, are what Elaine Aron calls “highly sensitive people” or HSPs. They tend to be aware of subtleties in their environment and are likely to have rich and complex inner lives. Although such sensitivity can be a real advantage in their chosen profession, our culture, unfortunately, has little tolerance for highly attuned or easily overwhelmed individuals. They are often thought to be overly fearful, inhibited or neurotic. Although some HSPs may exhibit these traits on occasion, they are not inherent characteristics of this personality type.

The majority of the people in the lives of HSPs may find them difficult to understand because of their sensitivity, their inability to relate to other people and so on. High sensitivity may open another pathway to the mood disorders and social isolation often seen in this population. Aron’s research on HSPs is invaluable with regard to performing artists.

Finally, it would be remiss not to mention the controversial relationship between mental illness and artistic talent. There are those who contend that a direct correlation exists between creativity and the prevalence of bipolar and schizoaffective disorders among artists. Kay Redfield Jamison makes a strong case for this link in her book Touched With Fire: Manic-Depressive Illness and the Artistic Temperament. Contemporary neuroscience has produced evidence both supporting and contradicting this point of view.

Performers are often perceived to be more narcissistic than are members of the general public, although no real evidence exists to suggest that narcissistic personality disorder is more common in this population. Counselors should be aware of their own biases in this regard while maintaining an open mind about the possible presence of mental illness and personality disorders in their artistic clients.

Challenges to counselors

Performers will challenge counselors in a variety of ways. Some may treat their therapy hour as a kind of performance. Actors are notably accustomed to impressing and entertaining strangers, so they may initially prefer to hide their vulnerabilities behind a veneer of cheerfulness (despite having perhaps complained of terrible anxiety when calling to make the appointment). Some members of this population may see you as an authority figure, akin to a “stage mom” or a demanding teacher or director. Monitoring these kinds of transference possibilities is essential to creating a strong therapeutic alliance and allowing your work to proceed productively. Likewise, it is crucial to pay attention to your own countertransference. How are the clients’ projections influencing you? Is their charm or likability getting in the way of accurately assessing their therapeutic needs?

Some performing artists have a difficult time expressing themselves verbally. This is where your creativity might come into play. If clients seem unable to put their feelings into words in session, you might suggest that they write something between sessions or perhaps bring in a monologue from a play that conveys what they lack the words for. I had a client who had trouble discussing her feelings directly but would write and perform her poetry as part of our work. Another client played his instrument in a session to express something that he couldn’t verbalize. Even if you are not trained as an art therapist, you can encourage artistic clients to find alternative ways to communicate emotionally.

Actors and dancers might ask you to attend one of their shows. Musicians may want you to come to a recital or a gig at a bar or club. They might bring in CDs or DVDs of their work and ask you for your assessment. These requests bring up thorny issues for counselors. Do you bend your boundaries to attend a performance? Do you accept a recording, and if so, do you agree to listen (or watch) and offer an opinion? I don’t think there are universal answers to these questions. As always, if you’re unclear on what’s best for your client (and your professional boundaries), seek consultation or supervision.

Counselors know that the “why now?” question is always important, but it could be useful to know that performers often seek help at certain predictable points in their lives. Psychiatrist Peter F. Ostwald, in his article “Psychotherapeutic strategies in the treatment of performing artists,” suggested a few such points: at turning points in their careers, when they seem to be faltering or failing professionally, after a career-threatening injury and when they feel overwhelmed by career-related loneliness.

One final set of challenges directly impacts your ability to work with this population. As previously mentioned, many artists don’t earn a lot of money and often lack health insurance. Scheduling also can be difficult because many performers work full- or part-time day jobs and have either rehearsals or performances during the evenings and on weekends. Counselors must be clear in their decision-making process regarding their desire and ability to be flexible with their fees, schedules or both. Adjusting your professional boundaries should be done carefully and deliberately to ensure that you are able to provide excellent care without resentment.

Concluding thoughts

Life in the performing arts has its rewards, but it is also a difficult and often frustrating way to make a living. The people who choose to pursue the arts professionally make many sacrifices to bring to life diverse forms of expression. There is exceptionally little glamour in show business, despite what you might see on an Academy Awards or Grammys broadcast. I am regularly amazed at the reactions I get when I tell people that I have played for Broadway shows, at a certain jazz festival or on a TV show. Invariably, folks will exclaim how much fun that must have been and how envious they are of these experiences. Yes, it can be thrilling to perform under certain rare circumstances, but most of the real work of artists is unseen, and most opportunities to perform occur under far-from-ideal conditions.

I have tried to provide a comprehensive overview of the psychological and cultural milieu of performers, and to suggest some new ways to think about the unique issues that counselors may encounter with this population. If you provide mental health services to people in the arts, know that you are serving a group of people who truly need you. Performers contribute so much of themselves to make our world a richer, more vibrant place. As counselors, we are called on to perform the related task of helping to create a healthier, more emotionally stable environment for all.

 

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Bill Harrison is a licensed professional counselor on staff at the Claret Center in Chicago, where he specializes in the treatment of performing artists. Contact him at counselorbill1@gmail.com.

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.

When post-abortion emotions need unpacking

By Bethany Bray April 3, 2018

Catherine Beckett, an American Counseling Association member with a private practice in Portland, Oregon, has made it a habit to avoid using “must” phrases with clients. “It sends a message to the client about what they’ve experienced,” says Beckett, who specializes in grief counseling. “I don’t ever want to say, ‘Oh, you must feel so guilty,’ or ‘You must feel so isolated,’ because that may not be the case at all.”

A case in point: when clients reveal in counseling that they have had an abortion at some point in their past. Some clients consider that experience to be just another piece of their life story, free of any negative associations. For others, the experience can evoke a range of issues, from spiritual and familial turmoil to attachment difficulties and feelings of loss. When dealing with such a highly charged topic, counselors must be prepared to put their own personal views aside to support clients who fall into either camp — and those who present a range of emotions in between.

Research cited by an American Psychological Association task force found that the majority of women who elect to have an abortion will not experience mental health difficulties afterward (see apa.org/pi/women/programs/abortion/). In February 2017, JAMA Psychiatry published a study titled “Women’s mental health and well-being 5 years after receiving or being denied an abortion.” The study observed 956 women over the course of five years, including 231 who initially were turned away from abortion facilities. Among the authors’ conclusions: “In this study, compared with having an abortion, being denied an abortion may be associated with greater risk of initially experiencing adverse psychological outcomes. Psychological well-being improved over time so that both groups of women eventually converged. These findings do not support policies that restrict women’s access to abortion on the basis that abortion harms women’s mental health.”

Even though most women will not experience long-term mental health problems after an abortion, some may still endure feelings of loss or encounter other negative emotions caused by external factors such as culture or family. For certain clients, a past abortion experience, whether it took place one month ago or decades ago, can be at the root of a range of issues — low self-esteem, relationship problems, disenfranchised grief — that surface during counseling sessions.

Beckett notes that most of the women she works with aren’t questioning their decision to have an abortion but rather “struggling to process it and place it in the narrative of their own lives in a way that feels comfortable.”

“As a practitioner, you should know about [abortion] and understand that within the population you’re seeing, it’s probably in their story,” says Jennie Brightup, a licensed clinical marriage and family therapist in private practice outside of Wichita, Kansas. “You need to be prepared to know how to work with it.”

Counselors should approach the revelation of an abortion just like any other experience or issue that clients may have in their histories, Brightup says. “Have an open mind. Allow it to be something that can be a problem for your client. See that it could be an issue … [and] have some knowledge about how to treat it.”

‘You think you’re alone’

The Guttmacher Institute, a reproductive health research organization, estimates that in 2014 (the most recent data available), 926,200 abortions were performed among women between the ages of 15 and 44 in the United States. This comes out to a rate of 14.6 abortions per 1,000 women.

The institute notes that this marks America’s lowest abortion rate since the process was legalized nationwide by the Roe v. Wade Supreme Court decision in 1973. The U.S. abortion rate has seen a steady decline after peaking in 1980 and 1981 at close to 30 abortions per 1,000 women. Using the 2014 data, the Guttmacher Institute extrapolates that 5 percent of U.S. women will have an abortion by age 20; 19 percent will have an abortion by age 30; and 24 percent will have an abortion by age 45.

Abortion is more common than many people, including mental health practitioners, think, says Trudy Johnson, a licensed marriage and family therapist who presented on “Choice Processing and Resolution: Bringing Abortion After-Care Into the 21st Century at ACA’s 2012 Conference & Expo in San Francisco. Johnson, who had an abortion in college, says that for many people, processing the abortion experience is “a slow burn. It doesn’t affect you until later on. [Many] women have had an abortion, but you think you’re alone. You don’t feel you get to grieve it. … It’s a gut-level thing, a tender place. Many have never told a soul,” says Johnson, who specializes in trauma resolution, including abortion-related issues.

Connecting issues

For clients who have yet to process and place a past abortion into their self-narrative, it can feel like a sadness that they can’t quite pinpoint or define. “It’s kind of like a phantom pain. It’s there, but you don’t know why,” Johnson says.

Clients with a variety of presenting issues may have unprocessed emotions surrounding a past abortion that could be compounding their struggles, Johnson says. These issues can include:

  • Depression and anxiety
  • Complicated grief
  • Anger
  • Shame and guilt (especially shame that is undefined or has no apparent cause)
  • Self-loathing and self-esteem issues
  • Relationship issues (including destructive relationships)
  • Destructive behaviors (including substance abuse)

For certain clients, their unprocessed emotions can feel like a weight they have carried and buried deep within themselves for a long time without sharing it with anyone, Johnson says.

Johnson recalls one client who initially came for couples counseling with her husband but eventually started seeing Johnson for individual counseling. During a session, Johnson recognized that the woman was becoming upset, so she handed her a blanket and pillow for comfort. The client put the blanket over her head, obscuring her face, and disclosed that she had had an abortion 18 years prior. Her family had shamed her for the decision, and her feelings of shame were still so overwhelming that putting the blanket over her head was the only way she could bring herself to talk about the experience, Johnson recounts.

“You just can’t imagine the shame that [some of] these clients carry,” says Johnson, a private practitioner who splits her time between Arizona and Tennessee. “They just have to talk about it. We, as professionals, can be that safe place.”

Clients who have had abortions sometimes question whether they have the right to grieve because there was a choice involved to terminate their pregnancies, says Beckett, who is an adjunct faculty member in the doctoral counseling program at Oregon State University. The concept of the experience of disenfranchised grief — those who are not supported in their grief because it is not culturally recognized or validated — applies in these instances, Beckett says. In fact, the disenfranchisement can be both external (a loss not recognized by the client’s culture) and internal (a loss that the client, individually, does not recognize).

“People do not have the same kind of support and validation [to grieve a loss] when they’re disenfranchised, and that is a huge part of abortion grief,” Beckett says. “The emotional aftermath is so impacted by spiritual, political and ethical values and beliefs. That will really color how they process it and how much they’re able to reach out and get support. This all needs to go into our assessment of a client. What was their experience, but also how are they talking to themselves about it? All of that should inform how we offer support.”

Broaching the subject

Practitioners might want to consider asking clients (female and male) about pregnancy loss, including abortion, on intake forms. Brightup asks clients about past pregnancy loss in a genogram exercise she does in the first few sessions of counseling. If the client mentions an abortion, she simply makes a note and keeps going. It is not a topic she feels a need to jump on immediately, she says, and she doesn’t want to risk retraumatizing clients or prompting them to talk about it if they are not ready. Some clients may not mention an abortion on an intake form or genogram because they don’t consider it a loss or associate it with trauma, Brightup says. Others have buried the issue so deep that they don’t think about it or feel that it is worth mentioning, she adds.

“When you’re hearing their story, you can find places to check in and ask questions. Most of the time, I allow them to come around and tell me. It’s a core secret. If you feel [judgmental] to them, they’ll never tell you and they’ll run [stop coming to therapy],” says Brightup, a certified eye movement desensitization and reprocessing (EMDR) therapist.

Practitioner language is also important, Beckett notes. “For some people, asking [if they have an abortion in their past] is giving them permission to talk about it. And the way we ask about it may give them clues about whether or not it is safe to talk to us about it,” she says. “For example, there’s a difference between, ‘Is this something you have experience with?’ and ‘Well, you haven’t had an abortion, have you?’”

Even the word “abortion” can provoke an intense reaction for some clients, Johnson says. In some cases, she will use the phrase “pregnancy termination” or even “the A word” with clients who feel triggered and begin to close themselves off.

“You might need to say it differently,” Johnson advises. “Abortion immediately turns it into a political, socially charged [issue]. Changing the terminology helps it to be safer.”

The key is to foster a safe, trusted bond so that clients will feel free to bring the topic up themselves when they are ready, Johnson says. “The most important thing is building a relationship of safety,” she emphasizes.

Different points on a path

Clients who disclose having an abortion in their past may vary widely on how they feel about the procedure and how much they have processed those feelings.

“There are clients who will come in and do not report having any mental health issues related to their abortion experience. Understand that they’re out there. But the other side is out there too,” Brightup says. Practitioners must be prepared to work with clients who express either sentiment — or a range of feelings in between.

Counselors should watch their clients’ body language and other cues, especially in cases in which a client is emphatic or even defensive when talking about an abortion. It is wise to unpack the client’s experience and associated feelings over time, Brightup says.

If counselors disagree with a client’s assertions concerning how she feels about the procedure, “you can lose the client because they won’t come back [to therapy],” she says. “Agree with their narrative. In little pieces, once they trust you, you can come back to the story and probe a little, ask a few questions as gently and carefully as you can.”

Some clients will have fit the abortion into their self-narrative and moved on, whereas others won’t be as far along in the journey. Still others will have worked through their feelings surrounding the procedure in a healthy way previously but may find themselves struggling with it again as they move into another life stage such as pregnancy or motherhood, Beckett says.

This was the case for one of Beckett’s clients who sought counseling because she was struggling with powerful emotions that had resurfaced. The client had undergone an abortion when she was 17. Later in her life, she had a daughter, and that daughter was now turning 17 herself. Even though her daughter wasn’t facing any type of decision regarding pregnancy or abortion, her age triggered feelings in the client that needed more therapeutic attention.

The client’s abortion had been illegal at the time where she lived, so she had felt compelled to keep it a secret, Beckett explains. The client realized her daughter was now the age she had been when she had an abortion. “The mother saw, for the first time, how young she [had been] and how desperately she had needed love and support at the time, and she didn’t get it,” Beckett says. The realization was “exquisitely painful” for the client, but at the same time, it brought “a new level of compassion for her 17-year-old self,” Beckett recounts.

“She took a great deal of comfort in knowing that if her daughter were to get pregnant, it would be an entirely different experience. Her daughter would have the support of her family and better care,” Beckett says.

The hard work of unpacking

Just as clients will differ in the work they have done — or haven’t done — to process the emotions surrounding an abortion, the support and interventions they might need from a counselor will also vary.

“People grieve very differently, and we need to be ready to support people however they are doing it,” Beckett says. “Some people are going to want to take action or give back somehow. Others will respond to more creative processes or ritual creation. Others will want a quiet, safe place to process.”

Normalizing a client’s experience can be a much-needed first step. Beckett says that talking about how common abortion is, and the fact that many people feel a need to process their feelings afterward, can bring relief to clients. Practitioners can also help clients reframe their thoughts to realize that feelings of relief after the procedure are common, as is a fear of judgment and a sense of isolation that can accompany that fear.

“Figure out what this particular client’s experience is and then, if appropriate, offer normalization of that,” Beckett says. “Support them to determine what is needed to move them toward greater comfort and peace. Offer them ideas and support around getting those things that they need.”

In Brightup’s experience, post-abortion work with clients often falls into four quadrants:

  • Reconciling how clients feel about themselves
  • Engaging in grief work around how clients perceive and feel about the loss (if they do indeed view it as a loss)
  • Working through clients’ spiritual issues or any inner tensions related to “rules” that were broken
  • Working on clients’ relationships and how they relate to people: Are there areas that need healing?

From there, practitioners should tailor their approaches to meet each client’s individual needs and pacing, Brightup says. She often uses sand tray therapy as a tool to help clients talk about post-abortion loss and find closure. Journaling, writing letters or poems, creating art and engaging in other creative outlets can also be helpful, she says. Certain clients may respond to creating some kind of physical memorial or taking time out of a counseling session to do a remembrance with just the two of you, Brightup adds.

Beckett agrees that counselors should collaborate with clients to find a ritual or activity that works for them. Although many clients will make progress through talk therapy or by connecting in group work to those who have had similar experiences, others will feel a need to take some kind of action, Beckett says. Creating memorials and rituals, writing letters or participating in other creative interventions can help these clients to process their emotions and experiences.

For one of Beckett’s clients, healing involved creating a special ritual on what would have been her child’s due date. Each year, the client would be intentional about spending time with a child — whether a niece or a nephew or the child of a friend — who was the same age that her child would have been.

“She came in pretty soon after her abortion, and she knew she needed help to process it,” Beckett says. “She wasn’t questioning the decision, but she was having trouble [with the fact] that her life would move forward but the life of the baby she had not had wouldn’t move forward. She wrote a letter to that baby expressing her caring and regret and explaining why she felt she couldn’t bring him or her into the world. Every year on her due date, she would find a way to connect with a child she knew that would be that age. She would spend time with that child and make it a good day for them.”

Whereas this intervention helped this particular client to find peace, “for other clients, the thought of that would seem hellish,” Beckett stresses. “There’s no prescription for this. It’s a process of figuring out what is still remaining and needs to be released. Talk with the
client to find creative ways to be able to do that.”

Counselors can help clients navigate areas in which they feel emotionally stuck, Beckett explains. For example, one of her clients was struggling even though she had worked through many of the emotions she had experienced after an abortion. The client had three children, and when she became pregnant with a fourth, she and her partner made the decision to terminate the pregnancy.

“There was one part that she couldn’t get OK with: ‘I see myself as someone who takes care of others,’” Beckett says. “That’s where we focused: How did she define ‘taking care’? How did this decision threaten her self-concept? We dove into that area and she eventually realized that terminating the pregnancy was taking care of her fourth child. That was the best way to take care of that child, instead of bringing the child into an already-overwhelmed system that wouldn’t have been able to provide what the child needed.”

Johnson finds narrative therapy a useful approach when focusing on post-abortion issues with clients. Giving them the freedom to tell the story of their abortion — how old they were, how it happened, who came with them that day — can be powerful, she says. Sometimes clients won’t remember the details about their abortion because they’ve blocked them out, Johnson says, but as they open up and talk about the experience in therapy, they often start to recall things.

“This has been in their head for years. When they finally start talking about it, they go on and on because that’s [often] what they need,” Johnson says. “You can see the layers coming off as they’re processing it verbally, the whole story. … Letting them talk about the details and tell their story is a starting point.”

When relevant, Johnson also helps clients identify all the points of grief connected to the abortion beyond the loss of a pregnancy. For example, clients might have experienced a breakup with their romantic partners or the breakdown of a relationship with their parents or other family members either leading up to or after the abortion. Giving clients permission to grieve and accept the loss of these things is an important step, Johnson says.

There are “so many layers to this. The main thing [for counselors] is being a safe place. The impact of a hidden abortion could really be affecting the outcome of your therapy if it’s not addressed. Be aware that there could be this issue under all of the other stuff [the presenting issues],” Johnson says.

“Treat this as a disenfranchised and complicated grief situation, and take out all the political mess and pros and cons,” she continues. “The client has already made a choice. Let’s forget about that and just work on the grief. They’re not the same person that they were when they made the choice. They’re a different person now, so they need to have permission to revisit that time in their life and be free of it. The therapist is kind of a vessel of freedom for that, and it’s a wonderful place. … You’re helping them overcome the bondage, pain and grief that’s been with them for so long.”

Putting personal feelings aside

Abortion remains one of the most politically and socially polarizing issues in modern-day America. Despite this — or, in some cases, because of this — certain clients are going to need to work through issues related to abortion in the counseling office. A practitioner’s role is to be a support through it all, regardless of his or her own personal views on the topic.

Brightup urges counselors to rely on their training, which includes setting personal opinions aside and being what the client needs.

Creating a neutral and welcoming space for clients to talk about such a sensitive topic is paramount, Johnson agrees. “If you don’t have any experience working in this area, you can do more damage without meaning to,” she says. “Or, for some people, there’s a hidden implication that if you help a client through feelings related to an abortion, you’re condoning abortion.” That is simply not true, she stresses.

Beckett agrees. “Clients need a safe and nonjudgmental space to share [about their abortion experience], and that’s hard for some counselors based on their own belief system. It’s not going to be easy for all counselors — that affirmation of [the client’s] right to grieve. [But] a client needs support to determine what is needed to move them toward greater comfort and peace. Offer them ideas and support around getting those things that they need.”

 

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Disclosing an innermost secret

As clients process post-abortion emotions, they may struggle with the decision to tell others, including a current or former partner. What should a counselor’s role be in that process? Read more in our online-exclusive article: wp.me/p2BxKN-54z

 

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Related resources

  • The upcoming ACA 2018 Conference & Expo in Atlanta includes an education session titled “Compassion and Self-compassion: Therapeutic Approaches to Heal From Grief and Loss” (Saturday, April 28, 7:30 a.m.). See the full conference program at counseling.org/conference.
  • For more on the mandate for counselors to practice competent, nonjudgmental care, refer to the 2014 ACA Code of Ethics at counseling.org/knowledge-center/ethics/code-of-ethics-resources. ACA members with specific questions can schedule a free ethics consultation by calling 800-347-6647 ext. 321 or emailing ethics@counseling.org.
  • Interested in networking with other ACA members on this and other related issues? ACA has interest networks that focus on women’s issues, grief and bereavement, sexual wellness and other topics. Find out more at counseling.org/aca-community/aca-groups/interest-networks.

 

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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 editorct@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.

 

Disclosing an innermost secret

By Bethany Bray March 26, 2018

Should I tell my partner about my abortion?

Fielding questions about sensitive and complicated topics is all in a day’s work for many professional counselors. This question, however, is one that counselors must handle with particular care.

Abortion is among an infinite number of scenarios that clients might want to work through with a counselor so they can fit it into their self-narrative. Telling others about their abortion, whether it occurred one month ago or decades ago, can be an action that some clients consider as they work through the feelings they may have related to the procedure.

Sharing their story — both in therapy and in other outlets — can be one of many potential ways that clients find release and closure, says Catherine Beckett, an American Counseling Association member with a private practice in Portland, Oregon. Counselors can offer support as clients weigh their options and decide whether to disclose an abortion to a former or current romantic partner, family members or friends.

“Help the client assess the potential risks and benefits of sharing, with whom and when, and support them in a decision they feel good about,” says Beckett, an adjunct faculty member in the doctoral counseling program at Oregon State University. “Help them thoughtfully consider and think through what is going to be the most right for them, and perhaps introduce different options [to them as the counselor].”

Trudy Johnson, a licensed marriage and family therapist who splits her time between Arizona and Tennessee, notes that when clients feel ready to tell others about a past abortion, it can be a sign of progress. At the same time, counselors should remind and help prepare clients that their family members and friends may not feel the same way that the client is feeling.

“You can share with others, but you have to be strong enough not to worry about how they are going to respond. Remember, they are not in the same place as you,” says Johnson, who presented on abortion-related issues at ACA’s 2012 Conference & Expo in San Francisco. “You just have to realize that the person you’re telling might not respond the way you’re expecting, and you have to be OK with that. I often get the question, ‘Do I need to tell my children?’ That doesn’t necessarily need to happen. You have to be very careful and make sure that’s what you want to do. Will it serve a purpose? Will it help them to know? Do they need that information?”

It is a delicate “gray area” that has to be considered on a case-by-case basis, Johnson says.

Explore the reasons why the client is feeling a need to share, Beckett agrees. Counselors should help clients find release, whether it is through disclosure or other outlets.

Some clients may ultimately decide that the risks of disclosing their abortion to loved ones outweigh the benefits. Risks include the possibility of difficult feelings regarding the procedure — including grief and shame or stigma from culture or family — resurfacing. Clients who decide not to share might find release instead by posting their story anonymously on an internet message board or by writing a letter they never send, suggests Beckett, who specializes in grief counseling.

For those clients who do decide to disclose their abortion, it might be best to start small, tell just one person whom they trust and then go from there, Beckett says.

“For those who really feel the need to share, determine what is the safest place or who is the safest person to share it with. Then see how that feels: Did it help? Do they want to share further?,” she says. “I think, as counselors, that one of the most valuable ways we can support these women is to serve as someone to talk to about their options, who is not going to pressure or push them in any particular direction.”

 

 

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Although most women will not experience long-term mental health problems after an abortion, some may still endure feelings of loss or other negative emotions caused by external factors such as culture or family. These feelings can surface in counseling sessions.

For more on this topic, see the feature “When post-abortion emotions need unpacking” in the April issue of Counseling Today.

 

 

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Follow Counseling Today on Twitter @ACA_CTonline and Facebook at facebook.com/CounselingToday.

 

 

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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.

 

 

Why neurocounseling?

Compiled by Bethany Bray March 12, 2018

Decades ago, you might have gotten some funny looks or raised eyebrows if you used the word “neurocounseling” in a professional setting. In recent years, however, counselors have become increasingly interested in using concepts from neuroscience to inform and support their work with clients.

What makes professional counseling compatible with neuroscience? How can it help counselors gain insights into human behavior and the challenges that clients bring into counseling sessions?

Counseling Today asked three practitioners for whom neurocounseling is an area of expertise, Thomas A. Field, Laura K. Jones and Lori A. Russell-Chapin, what draws them to this topic.

The trio are co-editors of the ACA-published book Neurocounseling: Brain-Based Clinical Approaches. Field is an associate professor in the master’s counseling program at the City University of Seattle; Jones is an assistant professor at the University of North Carolina at Asheville; and Russell-Chapin is professor of counselor education at Bradley University in Illinois.

 

Q+A: Why neurocounseling?

 

Laura Jones: Coming into the field with graduate degree in cognitive neuroscience, I have always playfully said that I do not know how to be a counselor without considering what is happening in the brains and bodies of my clients — both the physiological factors that have led to their struggles and resilience as well as the neurophysiological corollaries of their growth. As a counselor-in-training and later a student in counselor education, I could find very little work discussing this connection and became passionate about trying to bridge the two fields.

One of my foremost professional endeavors is to facilitate the intentional and informed integration of neuroscience into our field in a way that honors our professional identity (as I am also quite passionate about professional advocacy as well) and in doing so enrich and increase accessibility to training in this area. I am endlessly excited by the emerging science that can, has and will continue to influence the mental health field. For example, how can we ignore research that suggests that levels of certain gonadal hormones (steroids) have the potential to influence an individual’s susceptibility to suicidal ideation and attempts, drug relapse, responses to traumatic stress, etc., or the burgeoning research that implicates dysbiosis (imbalance) of our gut microorganisms (e.g., bacteria) in our mental health, or the fact that our body’s immune response has implications on mental and emotional wellbeing.

Although Descartes’ mind-body dualism has long been disproved, we (mental health and medical practitioners alike) often still function, largely implicitly, from this paradigm. Each and every day, researchers are substantiating just how complex this connection truly is, thereby underscoring how we can no longer work in health silos. This integrative perspective is the future of mental health.

Counselors have the opportunity to learn from other fields and use this information to strengthen our work with clients and our field as a whole. I firmly believe that counselors are well positioned to provide valuable and unique contributions to broader deliberations, research initiatives and policy efforts in the national mental health sector, and in doing so, secure our position as a leader among the mental health professions.

Another reason that I have become so passionate about this work stems directly from clinical experiences, much of which has centered around work with trauma survivors and individuals struggling with substance use disorders. I cannot express how powerful and empowering it has been for clients with whom I have worked to understand how processes in brain and body may be contributing to their struggles. The phrases, “So, you mean I’m not crazy?” “It makes so much sense!” and “Can you please explain that to my family?” have been used more than once. As counselors, we also are well aware of the pervasive and damaging stigma shrouding mental health challenges and those who are struggling. Most individuals with clinically diagnosable disorders never get the help they need, owing largely to this stigma.

Providing a physiological rationale for mental health challenges can significantly reduce mental health stigma; make mental health, often considered an enigmatic concept, more tangible; and alleviate the blame and shame that those who are struggling frequently experience.

 

 

Thom Field: Neuroscience attracts me for several different reasons. First, I think neuroscience provides a scientific basis for understanding important foundational concepts about human development, the impacts of oppression and marginality and the centrality of the counseling relationship. It has already provided us with significant insights into why certain problems develop at different stages (e.g., why the emerging adulthood years make a person susceptible to develop bipolar disorder or schizophrenia; see Seth Grant’s genetic lifespan calendar). Second, certain clinical issues are better understood and addressed through the lens of neuroscience, such as traumatic brain injury, posttraumatic stress, substance use, autism, attention-deficit/hyperactivity and even depression. One of my close family members has a diagnosis of schizophrenia and another autism, so understanding how to prevent and treat these conditions is important to me personally. Third, neuroscience helps to explain why we respond to certain events, such as why our physiological systems become activated in response to threats in the environment, leading to quick and often automatic decision-making and action such as aggression. I am part of a team that has developed a therapy model around this concept (neuroscience-informed cognitive behavioral therapy (CBT); see the website http://www.n-cbt.com/ for more information). Fourth, many of my fellow counselors and students continue to underprioritize Maslow’s basic needs like sleep, and sometimes do not ask about this during the first meeting with a client/student. Fifth, and perhaps most important, neuroscience offers promise for the discovery of new information about the brain and body that can make us more effective professionals.

Most psychotherapy research is limited by self-reported data (which is largely unreliable) and has largely failed thus far to distinguish specific behaviors and interventions on the part of the counselor that lead to more effective client outcomes. For example, meta-analyses have found that most counseling theoretical approaches are equivalently effective, and component studies have found that specific components of a model (e.g., the trauma narrative in trauma-focused CBT) are relatively unimportant to overall effectiveness. Thus, while psychotherapy generally appears to be effective, we still have little clue as to what factors make counseling more/less effective.

I believe that the objectivity of brain imaging and measures of neurological activity may help us to better measure what makes counseling more/less effective in the future.

 

 

Lori Russell-Chapin: I have been teaching and practicing counseling for at least three decades. It seems that many clients are searching for methods to help them feel better. So many of my clients have been to several counselors who have been helpful, but the clients are needing, wanting and searching for “one more thing” to help with their psychological and physiological concerns. Neurocounseling, or bridging our brain to behaviors, is the missing piece or “thing” of the puzzle.

As I teach students, clients and other helping professionals about neurocounseling, an all-encompassing phenomenon seems to occur. Without exception when people begin to learn more about the brain and body connections, they often comment, “If I can control my breathing or heart rate or skin temperature, then perhaps I can control so much more in my life!” Offering people self-regulation skills teaches intrinsic locus of control and personal accountability. Neurocounseling strategies demonstrate on an individual basis quantitative measures to show counseling efficacy measures. An example of this is a client who enters the counseling office with a skin temperature of 75 degrees. With one skin temperature imagery exercise, the client may be able to raise the skin temperature 5 to 10 degrees. I have had clients literally skipping out my office because they have learned this simple but essential biofeedback tool. This is an outcome measure at every counseling session.

Another fun example of neurocounseling: I wear biofeedback/temperature control nail polish. I am constantly getting feedback about what is going on in my day. This is a constant reminder for me to diaphragmatically breathe, slow down and self-regulate!

Teaching others about neurocounseling doesn’t just help them with situational symptom reduction, but it teaches a unique approach to wellness, life and a method for adapting and regulating through life’s difficulties.

 

 

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Related reading, from the Counseling Today archives:

 

 

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Want to connect with other counselors who are interested in neuroscience? Join ACA’s Neurocounseling Interest Network. Contact Lori Russell-Chapin at lar@fsmail.bradley.edu or visit neurocounselinginterestnetwork.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.