Tag Archives: Counselors Audience

Counselors Audience

Cross-cultural counseling of recent immigrants

Christina M. Rasmussen July 18, 2011

It is a common belief that clients seek counseling to begin or continue change. In the case of recent immigrants, change is a significant, ongoing process. Deciding to leave one’s home country to make a new life somewhere else requires considerable bravery and faith that the future will be as good, if not better, in another place. But the enormous demands of such a transition often exceed even the most realistic expectations. I have friends who, upon visiting the United States for the first time, were awed by the openness and freedom of American culture but simultaneously startled by the traffic, grit and destitution they observed.

This is supposed to be the land of opportunity, but for many who live here, life is still very, very hard. The new immigrant will not only witness such disheartening scenes, but may, in fact, be living them out on a daily basis — a circumstance that can produce considerable disillusionment and regret. It is important for culturally sensitive counselors to recognize and validate the immigrant client’s culture shock and efforts to persevere in the face of these challenges and disappointments.

New arrivals to the United States often endure a considerable amount of psychosocial upheaval as they struggle to adapt to a new culture, language (possibly), social structure and financial reality. Their economic circumstances substantially impact such transitions. Individuals or families with adequate, stable incomes are likely to find such adjustments less difficult than those with minimal funds. Having the time and resources to maintain connections with significant others, either in the new community or back home, and the ability to access needed or desired products, such as traditional food items, can also affect the ease with which they adjust to their new environment.

Being unable to communicate in English is socially isolating and limits employment opportunities. Even immigrants who are verbally fluent and functionally literate may be puzzled by regional language patterns and colloquialisms, contributing to their sense of being out of sync with others. Dining and sleeping, activities that, depending on the immigrant’s culture, might previously have taken place on the floor, now involve tables and beds. Holiday customs, such as the exchanging of Christmas gifts, may be unfamiliar. Moreover, any obvious differences in speech or appearance can make these individuals vulnerable to unusual scrutiny or prejudicial treatment. For instance, during the sniper attacks that took place in the Washington, D.C., metro area in 2002, police stopped one of my students who was traveling in a vehicle similar to the one reportedly driven by the suspects and subjected him to particularly close examination because he was Turkish.

Political refugees and asylum seekers confront challenges of an entirely different order of magnitude. At best, they face the prospect of indefinite separation from family members who were unable to accompany them. At worst, they have witnessed the killings of loved ones or been tortured or maimed themselves. Survivors endure tremendous emotional losses, in addition to post-traumatic stress, and may require treatment for physical as well as psychic wounds. (The Center for Victims of Torture provides resources for survivors and clinicians through its websites: cvt.org and healtorture.org.)

Although recent immigrants are subject to a myriad of stressors, counseling is unlikely to be the first resource to which these individuals ordinarily turn. Generally, family members form their most important support system. The immigration process itself has likely strained these relationships, however, either due to increased physical distance from loved ones or because relatives who immigrate together frequently adapt to the new culture at different rates and to varying degrees. When separated from one’s biological family, the larger circle of those with shared heritage and experiences may become an important substitute. Comfort might be derived from common religious observances or mere proximity to others who speak the same dialect.

Once an immigrant client does present for counseling, it is important to explore the circumstances leading up to this event. Although some of these clients come voluntarily, others may be mandated by the court to attend counseling. In the latter case, domestic relations or child-rearing practices are sometimes significantly different in the client’s country of origin, and the individual might not have a clear understanding of why his or her accustomed behaviors are not accepted in the new locale. Counselors may need to spend a substantial amount of time familiarizing these clients with American culture, including key aspects of the legal system, and helping them to identify healthy ways of accommodating new demands without abandoning traditional and personal values.

In certain instances, clients’ children or other relatives encourage them to seek professional guidance in coping with some life problem. One of my friends who is a therapist was recently approached by a former client, a college student who is a first-generation immigrant from Afghanistan. Her family still struggles with issues related to their relocation some years earlier and is attempting to cope with long-ago losses that continue to haunt them. My friend and I talked at length about the availability of low-cost or free services from a competent provider who would be willing to visit the family in their residence. We concluded it was also important to find someone who would recognize and honor the family’s cultural and religious principles.

Whatever the client’s presenting issue, it can be helpful to devote some time to exploring any ongoing cultural conflicts. One of my clients noted the substantial differences in etiquette between her Caribbean culture and that of Americans living in a semirural region of the Midwest. She was accustomed to greeting everyone with a pleasant “Good day” or “Good night” but found that this struck others as odd, particularly because “Good night” is generally used as a farewell rather than a welcome in the United States.

It is essential to view the immigrant client as an individual rather than as a stereotyped representative of a particular group, even if he or she identifies strongly with a certain faction or places high value on membership in a given community. For example, the term “South American” encompasses a wide variety of cultures and ethnicities, but it provides an insufficient description of a specific young mother whose ancestors were part of the indigenous population of Bolivia. Furthermore, people of common nationality may be members of tribes that have long been at odds with each other. Clients who were in the majority group in their home countries may suddenly find the tables turned, increasing their sense of displacement. In other cases, civil conflicts have resulted in the creation or dissolution of state boundaries, often without consideration for the ethnic identities of the affected people, many of whom were forced to flee their homes to escape the fighting. Among the places where this has occurred are the Balkan states, the Kashmir region of India, the former Soviet Union, Korea and various parts of Africa.

A key element of establishing rapport with immigrant clients is getting a sense of their internal rhythms and learning to work at a pace that is optimal for them. While at some point it may be appropriate to challenge these clients to stretch beyond their comfort zones, this cannot be broached effectively until trust is established and they feel respected and understood. Especially in the case of a cross-cultural counseling relationship, it is incumbent upon the therapist to become familiar with the client’s social traditions and principles. Prescriptively imposing one’s own standards implies a value judgment, which is likely to leave the client feeling further alienated.

As a counselor begins to understand the client in context, he or she might discover a wealth of sociocultural resources available to support the activities taking place in session. Members of the client’s family, religious organization or other community groups may be quite willing to encourage the client’s personal growth if the counselor explains the importance of their support and invites them to contribute their unique wisdom and understanding to the process. Working in concert with the client’s value system and traditions instead of against them is much more likely to result in a successful outcome.

Finding a way forward together

Lynne Shallcross July 12, 2011

Finding a way forward togetherWhen Kim Olver set out to find 100 happy couples to profile for a book, it turned into a much tougher task than she had ever anticipated. It also affirmed for her the genuine need for a book about making relationships work.

“It took me two years to find 100 happy couples willing to take my anonymous online assessment,” says Olver, whose book Secrets of Happy Couples was published earlier this year. “I believe there was a lot that contributed to that challenge. I think there are a lot of couples out there who are merely existing. They aren’t particularly happy, but they stay together. I also think people are busy and didn’t want to get involved. Some were interested until they saw the personal nature of the questions and then dropped out. And I think trust was a factor. Could their partner find out what their responses were?”

The theme of Olver’s book turned out to be that each of us holds the key to our own happiness in our relationships, which is a premise of William Glasser’s choice theory. In Olver’s opinion, counselors can boost couples’ happiness levels by helping them embrace and practice that lesson. “When people stop looking to their partner to change so their life can improve and instead start looking inside themselves to decide what needs to be adjusted, then they can be much happier. They are focused on something they control — themselves — instead of something they have no control over — their partner,” says Olver, a member of the American Counseling Association who runs a private practice in Chicago and serves as executive director-in-training for the William Glasser Institute.

Helping clients find happiness and fulfillment in relationships isn’t relevant only to counselors who specialize in couples counseling, says Thelma Duffey, professor and chair of the University of Texas at San Antonio Department of Counseling. “People don’t live in a vacuum, and problems rarely exist in isolation,” says Duffey, a member of ACA who also runs a private practice in San Antonio. “It is helpful when counselors have an understanding of the dynamics that affect people in their various relationships, particularly their important ones. Couples counseling training can be useful in this regard. Also, it is helpful when counselors working with individuals can look at a larger context. A couples counseling perspective supports this focus.”

Also required of effective counselors is an open-mindedness to the ever-changing dynamics that define who today’s couples are and what they look like, Olver says. “Research shows the younger generation is saying they are more ready to be parents than to commit to a marital relationship. I think couples counseling will need to evolve more in the direction of relationship counseling than marriage counseling. A therapist needs to be flexible enough to think of all possible relationship choices.”

Jill D. Duba, associate professor and coordinator of Western Kentucky University’s Clinical Mental Health Counseling Program, agrees. Acknowledging diversity in relationships and remaining open to hear every client’s story is key, she says, no matter the life stage, disability, sexual orientation or other difference from couple to couple.

When Duba, a member of ACA, became program coordinator, she revised the program so that courses on couples counseling and family systems were required. “My belief is that every individual is a relational being, period — whether they’re struggling to be in a relationship or they’re [already in one],” says Duba, who is also a member of the International Association of Marriage and Family Counselors, a division of ACA. “It’s imperative that a therapist knows something about how relationships work, how they don’t work and what are some things to look for.”

Duba points to Glasser’s reality therapy, which contends that people’s problems and unhappiness can almost always be traced back to their struggles in relationships. “[Relationships] are a function of who we are, and if we’re going to go out there and help people become whole, we have to know something about how [clients] perform and get along with others,” Duba says. “We have to be able to do that kind of counseling.”

A question of commitment

Olver says the issues that bring couples through a counselor’s door are wide ranging. Sometimes, there are power struggles over finances, with one person desiring to spend a little more and the other wanting to pull back. The recent recession and accompanying job losses have made issues involving household finances that much more volatile,
she says.

“I also find that the sex issue is on the table still,” Olver says. “Often, one person in the couple would like to have more sex than the other person would.” Outside relationships are another common point of contention, Olver says, whether one member of the couple has a close relationship with a coworker of the opposite sex or maintains connection with a former boyfriend or girlfriend via e-mail or social media. The tension most often springs from one partner feeling threatened by the romantic potential of the other partner’s outside relationship, Olver says, even if that friendship is strictly platonic.

An overarching theme Olver sees in her work with couples is that people enter into relationships and then often begin trying to mold or change their partner’s behavior or character. “Instead of learning how to accept that as the total package, they either consciously or unconsciously work over time at getting the person to become who they want them to be,” she says. “It’s really about not accepting the other person as they are.”

No matter the specific issue plaguing the couple, Olver’s first order of business is asking both partners if they are truly committed to working on the relationship. Many people come to counseling in a last-ditch effort to fix long-term problems, Olver says, and they aren’t always committed to doing what is necessary to save the relationship. If only one of the individuals says she or he is committed to salvaging the relationship, Olver will work with that person because she believes strongly that one partner’s efforts can ultimately change the relationship for the better.

Olver next educates the couple on whose behavior each person can control. People spend much of their time trying to change the behavior of others, Olver says, but in counseling, she aims to help clients realize they need to focus on making self-adjustments because they are the only ones they are directly capable of changing. “The idea is the only person you can control is yourself,” she says. “It takes the idea off of, ‘If [my partner] would just …'”

Next, Olver asks the couple what brings them into counseling. She lets each person have the floor to speak, then asks the person to listen to his or her partner, and then gives the person a chance to rebut. It’s crucial that the counselor remain neutral in this part of the process, Olver says. “There can’t be an ‘Oh, yeah, that sounds logical’ to what someone says. Neither one of them is right or wrong. They’re both right from where they come from, and that’s really critical.”

After all the complaints are on the table, Olver asks the couple to flip things around and tell her what’s right with their relationship and why they’d like to see it survive and thrive. The underlying goal, Olver explains, is to help the couple get in touch with their internal motivations for working on the relationship. Olver has the couple address the negatives in their relationship first before moving into the positives because she wants these positive aspects to be more present in the couple’s mind as they move through the session. “That’s where I want their attention focused as we move forward,” she says.

Olver then asks each person to think of one thing he or she could do in the upcoming week that would greatly benefit the relationship and then tells the couple to commit to following through on that action every day. She points out that this technique is different from traditional marriage counseling, in which the counselor might offer a recommendation to the couple based on the information they have provided. Olver stays out of the process, allowing the couple to decide what the next steps will be.

Olver uses Glasser’s choice theory in her work with couples because it steers clear of external control and encourages clients to make changes based on their own motivations. If the counselor makes a recommendation to the couple, it might sound as if the counselor is subtly siding with one partner or the other, even if that is not the counselor’s intention, Olver explains.

When Olver meets with the couple the following week, she says it’s immediately apparent whether both followed through on their “homework.” If they did, it frequently seems as if a “magic” change has taken place, Olver says, and the couple is often “good to go” after that. She explains to the couple some of the steps and techniques she used with them in the first counseling session so they will have them at their own disposal in the future if need be.

If only one partner completed the homework, Olver again raises the question of commitment to the partner who didn’t follow through. If the person isn’t committed to working on the relationship, Olver says she will move forward and work with the other half of the couple who is.

According to Olver, that invested client has three options moving forward: change, acceptance or leaving the relationship. Unless safety is an issue for the client, Olver recommends that leaving be the last resort. Oftentimes, clients have spent many years trying to change their partners. In working with the one person, Olver turns the focus on how that client can change himself or herself in order to change the relationship.

Olver recalls one client who was very frustrated with her husband’s workaholism and felt unloved because he worked such long hours. Through therapy, she was able to see that her husband was working hard and giving up his free time to get them out of debt because he loved her. “Once she was able to shift her perception from ‘That behavior means he doesn’t love me’ to ‘He really does,’ their relationship really changed,” Olver says.

Clients can also choose to come to terms with whatever is bothering them about their partner, accepting that it’s part of the whole package of the person whom they love. Part of acceptance, Olver says, is taking off the “complaining lenses” and putting on “appreciation lenses.” Sometimes, Olver asks clients to write down the things they don’t like about their partner. Then she asks them to consider how those “bad” things might potentially be helping them in some way. Clients achieve that acceptance when they can recognize that their partner is a whole person. Even when it feels like one bad aspect makes up 95 percent of that person, in reality, it’s only a small part of who that person is.

Although acknowledging that it’s wonderful when both members of a couple do their homework and work out their problems together, Olver says much can be accomplished even when only one person is invested in improving the relationship. Oftentimes, she says, one person in the couple is unhappy, while the other person minimizes those feelings or is oblivious to them. That’s not necessarily because the person doesn’t love the partner who is unhappy, Olver says, but rather because that person doesn’t perceive the relationship as being in trouble.

“This is when seeing one part of the couple is appropriate,” she says. “One person can adjust his or her behaviors, expectations and desires, and/or perceptions, all of which will significantly change a relationship. A relationship is a system. Change any part of that system, and the rest must adjust to compensate for the new change.”

Identifying blind spots

One of the tools Duffey relies on in couples counseling is the Enneagram personality typology. In helping describe the various ways people perceive the world and automatically respond to stressful events, the Enneagram can increase clients’ awareness of their thought patterns, beliefs and behaviors, she says. “I like using the Enneagram in couples counseling because it offers a neat way for people to gain insight into themselves and to learn more about their partners,” says Duffey, the Association for Creativity in Counseling’s representative to the ACA Governing Council and editor of the Journal of Creativity in Mental Health. “It can help couples identify the strengths, challenges and motivating beliefs that often drive each person’s choices and behaviors. One of the significant markers of successful couples counseling is the willingness of both people to invest in their relationship. When two people are invested in maintaining their relationship, this understanding can go a long way in helping to make that happen.”

As described by Duffey, the Enneagram is a typology consisting of nine personality types, three subtypes and nine levels of psychological development, with people falling on a continuum within each type. The relevance of the Enneagram to couples work lies in its ability to move couples out of their automatic way of responding during conflicts and to look at situations from another’s perspective, she says. “When we are able to step outside of ourselves and consider the other person’s experience of the situation, we are better able to see our impact on others. This can only be a good thing for couples wishing to invest in their relationships,” Duffey says. The Enneagram also provides a framework for counselors to assess and plan interventions on the basis of the couple’s types and levels of development.

Assessing each person’s current level of functioning is a key component to the tool, Duffey says, because it influences the individual’s response in challenging situations. “The Enneagram can help people identify their blind spots and Achilles’ heels and develop more productive ways of thinking and responding to situations that affect both people in the relationship.”

“Couples counseling is not typically smooth or easy,” Duffey continues. “There are many variables that contribute to its success.” For one, she says, clients need to possess enough self-awareness to tell themselves the truth about the role they play in certain situations. They also need to care about their impact on the other person and develop empathy. Partners capable of reflecting on their behaviors and motivations are generally able to make adjustments that communicate to the other person that they care. “I have found the Enneagram to be a helpful tool in this work,” Duffey says. “Couples report the good feeling that can come when they become more personally accountable, generous and, at the end of the day, more satisfied in knowing they are doing their part to make their relationship a good one.”

In Olver’s office, clients take a compatibility survey that highlights areas in which the couple is alike — and not so alike. Couples answer questions geared toward determining how high each person scores on the five basic needs: survival, love and belonging, power, freedom and fun. “Then couples look at where they are compatible and where their challenges may come in and work at negotiating the problem areas,” she says.

Another exercise Olver finds helpful involves two large rubber bands knotted together in the middle. Olver then asks the couple to place a piece of paper between them and to draw a dime-sized dot on their respective ends of the paper. She next instructs the couple to center the knot of the rubber band over the dot closest to them. “As you might imagine, there are many possible outcomes,” Olver says. “Some people will pull hard to win, some give up and let their partner win, and some cheat. Occasionally, they work out a compromise, but that doesn’t usually happen until I ask them to think of as many ways as they can to come up with a way they both could win.”

“Some solutions involve taking turns, folding the paper so the dots come together, opening the knot on the rubber band to encompass both dots or creating a third dot that’s in between the original two,” she continues. “After couples see how many solutions there are when they decide to work together for both their good, I ask them to brainstorm a way for both of them to be satisfied in an area where they have been experiencing disagreement. They can often move past blocks in this way. I call this the win/win/win solution. Both partners win because they are happy with the solution, and their relationship becomes stronger for going through the process.”

The genogram is another helpful tool that Duba uses with couples. One couple with whom Duba worked had been married approximately 35 years. Their marriage had gone well but then suddenly started turning in a negative direction, complete with high anxiety and numerous arguments. In talking with the couple, Duba keyed in on how the wife repeatedly brought up stories concerning her childhood and feelings of insecurity. So Duba turned to the genogram for help.

As the wife worked through the genogram, it became clear that much of her anxious behavior as an adult — which would in turn upset her husband — was rooted in circumstances she had experienced as a child. The husband watched and listened intently as his wife shared these stories, and he mentioned afterward that the exercise helped him to better understand his wife and her triggers. Duba was also able to work through some of those issues with the wife, including encouraging her to develop self-soothing strategies so she could remain present for her husband even when she began feeling anxious.

Theoretical approaches

Counselors point to a variety of theories that guide their work with couples. Olver tends toward choice theory and reality therapy. With reality therapy, she says counselors can help clients assess whether their behaviors are moving them toward the things they really want. “Ask them, ‘What do you want, what are you doing to get it, is there anything you’re doing that’s getting in the way, and is it going to work?'”

Olver describes choice theory as an internal motivation psychology as opposed to something the counselor imposes on the client. With this approach, she says, counselors can “go under the surface to find out what does the person want that they’re using this behavior to get? They may not be honest about it with the counselor or they may not be sure what it is, but when someone is misbehaving, I always ask myself, ‘What is this person trying to get?'”

Stemming from choice theory, Olver developed another model she calls Inside Out Empowerment that deals with subconscious motivations. Counselors can use the approach to get at the subconscious material that might be holding clients back from happiness, she says. “Sometimes, it simply involves asking clients to be still enough to listen to that little voice inside their head,” she says. “We all have this voice that talks to us and, often, it is not a supportive one. This subconscious voice carries messages of how we are not good enough for the things we want. One question I use a lot is, ‘If you stopped doing the destructive things in your relationship you have been doing, what do you think will change that you might not like?’ Another way is to ask, ‘If you make the changes you say you want to make, what would you have to give up?’ These are not common questions, and sometimes the answers are surprising and seem to come from a place deep inside ourselves.”

Duffey was trained in systems theory, which she says assists counselors in conceptualizing the dynamics of couples and families. Through the years, she has also incorporated relational-cultural theory (RCT). “RCT, which is in some ways a philosophy of human development, offers a helpful perspective when working with couples,” she says. “It discusses how we all have a desire to form connections with others. Still, many of us behave in ways that keep us from enjoying the very connection we desire. RCT theorists describe this as the central relational paradox.” The theory acknowledges that all relationships suffer disconnections, Duffey says, but problems arise when those disconnections become chronic. “The good news is people can develop more supportive ways of relating to one another, and couples are able to move out of isolation and into reconnection,” she says. “This is the thrust of couples counseling from an RCT perspective.”

Duba uses John Gottman’s “Sound Marital House” model, which emphasizes friendship as an essential piece of the marital foundation. Gottman’s research has found that couples will likely struggle with problems perpetually throughout their time together, Duba says, but the health of the relationship is based in how the couple talks about those problems more so than in finding a solution to them.

Duba is certified in reality therapy and is pursuing a certification through the North American Society of Adlerian Psychology, but she is also very systemic in how she sees couples. “It’s very important to understand how each individual developed from childhood, how they came to know their reality as a child and how that fits into this new system of the relationship,” she says. This is pertinent especially in situations in which couples are experiencing values-driven conflicts. Those values have developed over time, she says, so to expect immediate change or compromise is unfair. Instead, Duba invites conversations with couples in which each person can express his or her point of view and where that view originated. “Having clients develop insight is really important,” she says.

Safety first

Domestic violence is clearly a difficult and tragic situation for clients to find themselves in. It can also prove to be a difficult and confusing situation for their counselors. Ryan Carlson, associate director of the Together Project at the Marriage and Family Research Institute at the University of Central Florida (UCF), says the topic is controversial in counseling circles because, on the one hand, advocates often believe that any violence within a relationship context centers around issues of power and control and, therefore, that counselors shouldn’t be working with the couple. “From the opposite perspective, counselors want to help everyone,” says Carlson, a doctoral student in counselor education at UCF. “We don’t like the idea that there might not be any hope for the couple.”

A possible solution, Carlson says, lies in creating partnerships between counselors and domestic violence experts so that each couple is assured of receiving the appropriate treatment for their specific situation. This idea was an integral part of the Together Project, a federally funded study geared toward providing relationship education to low-income married couples. From the start of the study, Carlson and his colleagues used a domestic violence screening protocol, which they had developed, with each couple. Whenever the protocol indicated a couple might be dealing with domestic violence, a local domestic violence expert would intervene and recommend whether safety concerns needed to take precedence over counseling.

The decision was often based on whether power and control were intertwined with the violence, Carlson says. When power and control issues are present, the first priority has to be safety, he emphasizes. But when the violence isn’t tied to power and control — when it is related instead to a lack of anger management or poor conflict-resolution skills — there’s a greater possibility that counseling can help alleviate the couple’s problems. In carrying out the study, the path forward was a collaborative decision between Carlson’s colleagues and domestic violence experts.

Although the protocol and attention to domestic violence were part of a study, Carlson says the project also has relevance for counselors working in private practice. “The point is to be aware. There is always the chance that [violence] exists within the couple, and if you don’t ask about it, they’re probably not going to tell you,” says Carlson, a member of ACA and IAMFC. If a counselor is working with a couple and doesn’t know about the threat of domestic violence, the counselor is likely to treat both individuals as if they are on a level playing field in the relationship. If a true power differential exists in the relationship, Carlson warns that the counselor could place certain clients at risk by asking them to talk honestly and openly in session, possibly inciting a violent reaction from their partner outside of session.

Counselors must inquire about violence within the relationship, preferably asking each partner separately if possible, Carlson says. If one of the partners acknowledges domestic violence, the counselor needs a plan of action and, here, collaboration is key, he says. Counselors should attempt to form relationships with local domestic violence providers who can offer assistance and guidance concerning whether persons being victimized in relationships need safety and shelter more than they need counseling. If that isn’t possible, Carlson recommends that counselors ask supervisors or colleagues to provide another perspective.

Carlson admits that uncovering violence in a relationship is tricky for the counselor. Particularly if power and control are involved in the situation, the counselor doesn’t want the perpetrator to know the victim has disclosed any information. And if client safety is the greatest need, the counselor must be careful in how he or she suggests that counseling be terminated. To avoid alerting the aggressor that the victim has disclosed information, Carlson says a counselor might explain to the couple that the presenting issues are more individual in nature and that the best route would be individual counseling before continuing with couples counseling.

In situations in which the violence isn’t a product of power or control and the counselor has collaborated with someone else in determining to move forward with the couple in counseling, Carlson recommends talking openly with the couple about instances of violence. He also advises asking the aggressor to acknowledge that violence is never a healthy or appropriate way to resolve conflict.

A variety of exercises can help couples resolve conflict more peacefully, Carlson says. Sharing the simple tool of a time-out with couples is useful, he says, as is educating them about their escalation signs so they can take a break and address issues later on when they’re not feeling overheated. PREP (Prevention and Relationship Enhancement Program) and PAIRS (Practical Application of Intimate Relationship Skills) are two curricula that Carlson recommends to help couples reconnect, hear and understand each other better.

Family of origin can also play a role in how couples deal with anger, Carlson says. “For example, one member of the couple may have grown up in a family where conflict was handled by yelling, screaming, threatening and other escalating behaviors. Therefore, this person may not know how to handle conflicting points of view any other way. Counselors can help couples identify and share with each other how anger was handled in their families and discuss how each member of the couple would like to see anger and conflict handled in their own relationship.”

Lessons from marriage veterans

Although research exists on couples who have been married for 25 years, Duba says there is very little research that addresses couples who have been together for 40 years or more. So, about five years ago, she decided to conduct a study focused on that population. Duba believes the successful relationship characteristics — and the unavoidable bumps in the road — she gleaned from those couples can offer valuable insight to counselors.

Duba interviewed 30 couples within an approximately 30-mile radius of Bowling Green, Ky. Each individual filled out a marital satisfaction inventory that covered topics such as marital interaction, communication, gender orientation, children and finances. After the questionnaires were mailed to her, Duba went to each couple’s home to conduct an oral history review.

Something that stood out from the interviews was the importance each couple placed on faith, which Duba acknowledges could be due to the fairly religious makeup of the area. But it’s also possible, she says, that faith might genuinely be an integral component of enduring marriages, regardless of where couples reside. The couples she interviewed credited their faith with helping them persevere through child rearing, financial struggles and adjustments to marriage, Duba says. She also found that happiness with gender role orientation was significant and highly related to marital satisfaction.

The most challenging times for the couples tended to be the first year of marriage, the years when they were raising children and when a spouse first retired, Duba says. The couples recalled the initial year of marriage being tough both financially and because they were often leaving their families of origin for the first time. Although admitting the first year of marriage was stressful, Duba says the couples also thought that period of their lives brought them closer together as spouses because they had to rely on each other. “Many of them said, ‘He or she was all I had,'” Duba recalls.

The couples also talked about how child rearing allowed them less time to spend together and put stress on their relationship, especially when the children became teenagers. The transition into retirement presented another common rough patch for couples. Duba heard complaints of how the husband’s return home disrupted the wife’s routine. Or in other cases, the wife had returned to work after the children left home, and she didn’t want to quit her job just because her husband had retired. “It was definitely an adjustment period,” Duba says.

Commonalities Duba uncovered that seemed to keep the couples’ marriages going included humor, praying together, a commitment to giving and taking, hard work and a determined mind-set. “Many of them said, ‘I promised I would marry him, and I was determined to keep my promise.’ It may have been related to religious values, but the word promise was a common thread.” The presence of hope was another factor, Duba adds. Many of the couples told her that even during the challenging times, “I knew we would get through it.”

In conducting the research, Duba found it especially poignant that even 40 years into marriage, all of the couples spoke fondly of how they met. “I thought that was phenomenal,” she says. “Despite any struggles, they still saw the good stuff. They didn’t lose sight of those great memories. That was apparent.”

Lynne Shallcross is a senior writer for Counseling Today. Contact her at lshallcross@counseling.org.

Letters to the editor: ct@counseling.org.

Couples counseling on campus

About two years ago, Christopher Adams conducted an informal poll of college counseling center directors to see if they offered couples and family counseling. Almost 90 percent of those who responded said they offered couples counseling, but most weren’t sure if students and campus staff members knew of its availability, possibly due to poor marketing and advertising, says Adams, who will be starting as an assistant professor in the Department of Behavioral Sciences at Fitchburg State University in Fitchburg, Mass., in the fall.

Couples counseling is increasingly needed on college campuses, Adams says, because the student body is changing, with more students seeking postsecondary education later in life and more students who are already cohabitating with partners. “I think [college] counselors need to have some awareness of that and realize students might benefit from different treatment modalities, including couples counseling,” says Adams, a member of ACA who has worked in college counseling centers for about four years.

Adams knows from personal experience how important couples counseling can be to a student. He was already married when he began his graduate studies and understands the difficulty of juggling classes with existing work, family and relationship responsibilities. “You can have a married or dating couple doing fine, but if school gets stressful and you don’t have an outlet for that stress, it can spill into the relationship,” Adams says. “And then that stress from the relationship can spill into school, and it can become a cycle.”

Although the specific technique used will depend on the problem each couple brings to counseling, Adams says thinking systemically and taking into account contextual issues is important when working with couples on campus. He also advises college counselors to draw from behaviorally oriented theories to strengthen couples’ communication skills, solution-focused approaches to assist couples in figuring out where they want to go and emotion-focused theories to help partners understand and validate each other’s emotional experiences.

Adams recommends that college counselors who want to offer couples counseling get additional training and seek supervision, in addition to remaining mindful of how cultural variations might influence what is considered appropriate counseling. College counselors must also make sure they are operating within their school’s guidelines, he says, because some schools require that all clients be students at the school.

To college counseling centers that are already providing couples counseling services, Adams offers some straightforward advice: Advertise and let as many members of your campus as possible know that this valuable resource is available to them.

— Lynne Shallcross

Don’t turn away

Lynne Shallcross June 1, 2011

Julie Bates offers a sobering thought to anyone who assumes that certain individuals choose a life of addiction. Bates, a doctoral candidate in counselor education at Penn State University, worked for three years at a methadone clinic in Massachusetts. One of her clients, a 23-year-old woman who exhibited track marks running from her shoulder down to her knuckles, had already been addicted to heroine and cocaine for a decade.

How had she gotten so far off track by the tender age of 13? Because her mother had injected her.

Bates, a member of the American Counseling Association, says that story stays with her wherever she goes, reminding her very clearly that clients with addictions need empathy and help, not judgment. While in treatment with Bates, the woman’s most difficult struggle involved rebuilding herself, redefining who she was after a decade of addiction and learning how to function as an adult without the addiction component.

In working with the woman for three years, Bates learned that addictions counseling is a long-term process. “Be patient,” she advises. “It’s not something that changes overnight or even over a couple months.” Although her client was able to stop using heroine after only about two months, it took closer to 10 months before there was any decrease in her cocaine use.

What helped the client finally make inroads in beating her addiction was writing letters to her mom, even though the letters were never mailed. In the beginning, the letters were positive, with the woman thanking her mom for her sacrifices and love. But as time went on, the letters became more “real,” Bates says, expressing such thoughts as, “Mom, you said you loved me, but you injected me when I was 13. What chance did I have?”

Through the process of writing the letters, the client realized she had been brought up to believe that when you love someone, you lessen their pain through drugs. Through counseling, she was able to tweak that worldview, learning that drugs do not equal love and that she was worthy of being loved on the basis of who she was, not what drugs she used or gave to others.

Counselors who don’t work in addiction clinics might not experience situations quite this extreme, but experts in the field warn that addictive behavior is often intertwined with many of the problems for which clients seek counseling. The realization that a client has addiction issues is daunting to many counselors who don’t specialize in that area. But Bates encourages those counselors not to turn away. “Don’t be afraid to talk to the client,” she says. “A big disservice would be ignoring [the addiction].”

Gerald Juhnke, professor and doctoral program director in the Department of Counseling at the University of Texas at San Antonio, says many clinical mental health counselors start their careers not wanting to work with anyone who has an addiction. In fact, Juhnke admits, when he set out in marriage and family counseling, he was one of those counselors who wanted to avoid addiction issues. But the reality is, when it comes to fairly common issues such as depression, anxiety or career and family problems, there is often an overlap with addictions, Juhnke says. Existing problems might compel a person to begin using drugs or alcohol or to engage in some other addictive behavior as a coping mechanism, or the problems the person presents with might be the result of a preexisting addiction. “Even though you don’t plan on seeing people with addictions, it will happen,” says Juhnke, a past president of the International Association of Addictions and Offender Counselors, a division of ACA, and former editor of theJournal of Addictions & Offender Counseling. “People rarely come in saying, ‘I have an addiction problem.’ They come in saying I lost my job, have problems in my family, etc.”

Sticking with an addicted client

Even when counselors don’t think they are skilled enough to work with addicted clients, Juhnke says automatically making a referral isn’t the best idea. Accredited master’s-level counseling programs include training in addictions work, so most counselors possess at least some knowledge in this area. Juhnke strongly recommends that counselors consult with a supervisor and then attempt to continue working with addicted clients. “The client might have a good relationship with you as the counselor,” he says. “If the counselor panics and says, ‘I can’t work with you anymore,’ then the client feels abandoned. They feel like, ‘I won’t tell anyone again that I have an addictions problem.’ If you’ve already got a good counseling relationship, don’t abandon the client. Get someone who can give you ideas and direction, and follow what they have to say,” advises Juhnke, who coauthored Counseling Addicted Families: An Integrated Assessment and Treatment Model with W. Bryce Hagedorn.

Kerrie Fineran, an assistant professor of counseling at the University of North Texas (UNT), offers similar advice to counselors who don’t specialize in addictions. She recommends that counselors seek supervision, educate themselves on the resources available in the community for addicted clients and refrain from automatically referring or including language in intake paperwork that indicates they won’t work with clients who are using. A referral may be necessary if a client needs help beyond what you’re able to provide, especially in cases in which outpatient therapy might not be enough, says Fineran, a member of ACA and IAAOC. “But the process of referral should be something that promotes hope and your belief in their ability to change and doesn’t destroy the trust they’ve built with you.”

If counselors are unsure about whether a client is exhibiting addictive behaviors, IAAOC President Juleen Buser says research often references the three C’s of addiction as a way to conceptualize some of the core characteristics. “Counselors can be on the lookout for these three C’s as they work with clients as a preliminary way to assess the presence of addiction: loss of control over addictive behaviors, despite the client’s aim to stop; compulsive use; and continued use regardless of negative consequences,” says Buser, assistant professor in the Department of Graduate Education, Leadership and Counseling at Rider University in Lawrenceville, N.J.

The addictions counseling field has made a significant transition over the past few decades, according to Juhnke. It used to be that most addictions counselors were former addicts in recovery, whereas now, Juhnke says, there is a movement of mental health professionals heading into the field with master’s-level degrees and a specialization in addictions work.

Juhnke notes the licensure situation regarding work with addicted clients can be complex. Requirements vary state to state, meaning that any licensed counselor might be permitted to practice addictions counseling in one state, while in another state, the counselor must also be licensed as a chemical dependency counselor to perform the same work. This can be frustrating and confusing, Juhnke acknowledges, especially for counselors with advanced degrees who are then informed they need yet another license to practice addictions counseling. On the positive side, he says, the effort to make the field more professional with licensed caregivers is laudable.

Although master’s counseling programs touch on addictions, Fineran says counselors who want to specialize in addictions work should seek additional training and continuing education opportunities such as conference presentations, workshops and specialty certification programs.

Addictions can come in the form of process or substance addictions, but regardless of form, addiction is still addiction, Juhnke says. “All addictions are very difficult. One isn’t more difficult than another. In general, substance disorders revolve around ingesting, inhaling, huffing, injecting or taking some type of substance. Process disorders generally revolve around ‘doing behaviors,’ such as gambling, shopping, eating, sex, pornography, running, weightlifting, etc. The No. 1 thing in treating addicted clients is respecting them and treating them as if they were your mother, father, sister or brother. Failure to treat persons with addictive disorders as a loved one first often results in misperceiving the client’s addictive behaviors as [being representative of] the person.”

Understanding the struggle

Students who enroll in Fineran’s drug and alcohol counseling class at UNT are going to feel deprived — and that’s just the way she wants it. Each semester, Fineran asks her students to commit to giving up a substance or a process for the duration of the course. The goal of the exercise is for the students to understand the process of addiction and develop empathy for the addicted clients with whom they’ll someday work.

“Many of them think that people with addictions should just stop, quit it and pull themselves up by the bootstraps,” says Fineran, who likewise commits to giving something up each semester. “It seems like a simple thing to stop something, but [with this exercise], they understand what the body goes through and what the mind goes through. They really struggle with it. They start to understand what individuals with these problems go through and gain an increased sense of empathy that they can tap into when working with individuals from this population.”

At the beginning of the course, about half of the students are excited to accept the challenge because they’ve been wanting to give something up but needed a nudge to follow through, Fineran says, while the other half are terrified and don’t see how the exercise will help them learn anything. By the end of the course, roughly 95 percent of the students say the exercise was an excellent tool that taught them about the process of addiction and about themselves.

Many of the students give up something that has a physical impact, such as cigarettes or caffeine, so it doesn’t take long for them to experience symptoms of withdrawal. Most of the students relapse at least once during the semester, so Fineran addresses that topic in class. Some of the students acknowledge that they simply no longer felt like abstaining, whereas others slip up without thinking, such as by ordering a Coke at a restaurant. Regardless of the reason, Fineran says, the students learn about the shame and guilt that accompany a relapse and, more important, learn about the process that led to their relapse. Fineran works with the students to create plans to recognize warning signs of a possible relapse and to head it off before it happens. The project is particularly worthwhile because these counselors-in-training may one day create similar plans with clients who have addictions, Fineran says.

The class also discusses how life presents continuing challenges in the recovery process. For instance, Fineran says, students who commit to giving up beer for the fall semester might not realize until later how this decision affects their football watching. Or perhaps they give up sweets only to realize what a challenge that will pose during the holidays. “They go home for Thanksgiving and find out what it’s like to live in a world where everyone else isn’t trying to give up what they’re trying to give up,” Fineran says.

In addition to giving up a substance or a process, Fineran asks her students to attend at least two recovery meetings in the community, followed by writing a personal reflection to share with their peers. The meetings are as impactful as the attempt to abstain from something, she says, because they show the students that real people — often those similar to themselves or even people they know — are struggling. In addition, students are often impressed and humbled by the sense of community and hope that they witness at the recovery meetings.

“People with addictions are often maligned,” says Juhnke, who requires students in his addictions classes to give up both a process and a substance for the semester in addition to attending multiple 12-step meetings. “We think they’re old drunks or old addicts and we shouldn’t pay attention to them. But if we think of them as moms, sisters, dads, etc., we see them as people, not as the behaviors.”

It can be easy to focus on the behaviors that often accompany an addiction — such as stealing, lying or cheating to secure another hit — without realizing that those behaviors take place as a result of a physical or psychological dependency, Juhnke says. “Take, for instance, an addict who steals his mom’s silverware or credit cards. We might say, ‘What a bad son.’ But those are the components of the addiction, not the person behind the addiction.” Putting his students in the shoes of an addicted person is an effective way of building empathy, Juhnke says.

Empathy is one of Carl Rogers’ core conditions of counseling, along with congruence and unconditional positive regard, but those conditions have a tendency of disappearing when the client has an addiction, Fineran says. “We often look at people and think, ‘Just quit! You lost your home, you lost your job, so just quit this.’ But empathy helps counselors see that clients with addictions aren’t really any different than other counseling clients.”

After their own struggles to give up a substance or a process, Fineran says most students realize that people with addictions are simply people with problems — just like everyone else. “It becomes less scary for them and less of a mystery about what addiction is about,” she says. “It’s really about people trying to make changes in their lives, which is the same as every other client who comes in who might not be addicted.”

“Without that empathy and understanding and care for our clients, I don’t understand how they could ever imagine that we believe in them,” Fineran says. “We need to believe in them. We need to believe that these people are worth the change.”

Motivation for change

Historically, treatment for clients with addictions has often been directive, confrontational and harsh, Fineran says, but the trend is moving toward a model that is more supportive and inclusive of Rogers’ core conditions. That’s good news, she says, because research shows people do better when they are encouraged and when someone helps them elicit their own motivation for change instead of simply “throwing the book at them.”

“One movement that has gained steam over the past two decades is a shift to treatment models such as motivational interviewing, which differ from earlier models that focused on more intensive confrontation of clients,” Buser says. “Motivational interviewing works from the premise that clients come to counseling at various levels of motivation. A counselor’s role is to meet the clients at their current level of motivation — not presuppose a client is ready for action when, in fact, [he or she] may only be contemplating the need for change.”

Buser says a counselor might first assess a client’s level of motivation and then work toward increasing that motivation. “Authors have discussed the use of scaling questions to assess readiness to change at the start of counseling. If a client is ambivalent about treatment, gentle questions and door openers can be used by the counselor to help the client explore this ambivalence. For example, a counselor might acknowledge the client’s tentativeness about change, while also pointing out the client’s dissatisfaction with at least certain elements of the addictive behavior.”

Empathy is a critical component of motivational interviewing, Buser says. “For example, clients who struggle with eating disorders, termed a process addiction, often hide their behaviors and experience a sense of embarrassment about … binge eating and purging behaviors. Empathy is critical in this sense, as clients will be more likely to open up and disclose their disordered eating practices if they feel accepted and understood by a counselor.”

Juhnke is also a proponent of motivational interviewing with addicted clients. Through the process of a counselor asking questions about which parts of a client’s life are going well and which parts are not, the client can reach a clearer understanding of what is going on in his or her life, he says. For instance, a client might present with marital problems, trouble holding a job or failing grades before the counselor figures out that an addiction is intertwined, Juhnke says. Although the client at first might deny that an addiction is part of the problem, as the counselor asks questions and the client continues to want a solution to the problem, he or she may begin thinking about the impact that addictive behaviors have on the situation. Motivational interviewing helps move clients from a precontemplative stage to a contemplative stage, Juhnke says, and often encourages them to “bite into the whole treatment process.”

If motivational interviewing doesn’t prove helpful, Juhnke next tries a solution-focused approach, which creates a target the client wishes to aim for. Instead of focusing on the problem and how bad it is, which can be overwhelming for the client, Juhnke says solution-focused techniques urge the client to think about what an improved life would look like and what changes need to take place to get there. “Clients can tell you what they need if you listen to them, and this allows them to have influence on the kind of treatment they need,” he says.

If a solution-focused technique isn’t the right fit for an addicted client, Juhnke recommends trying a cognitive behavioral approach in which the counselor helps the client gain insight into his or her addiction triggers and how to respond once those triggers hit. For example, with a client who comes home from work to an empty house, feels lonely and reaches for a beer, Juhnke might ask the individual for alternative ideas of how that void could be filled. Keep in mind, he cautions counselors, that the same solutions won’t work for every client.

Buser mentions additional therapies that are sometimes referred to as the “third wave” of addiction treatment, including narrative therapy. “Counseling strategies associated with this theory include externalizing the problem, which often involves naming the problem,” she says. “Counselors work to separate the addiction from the client, often by giving the addiction a name, such as ‘bulimia’ or ‘alcoholism.’ The idea is that, through this process of externalizing, clients will no longer internally connect with the addiction. Clients may come into counseling with the view that addiction is a part of them. In this narrative therapy technique, however, the addiction is cast as an external force, and the client takes on the role of actively working to fight against this addiction. Optimally, this reduces self-blame and inspires efforts to combat the addiction.”

A different kind of referral

Clients with addictions won’t always come through a counselor’s door by their own volition. Instead they arrive because they are mandated to counseling by the court system. Although that circumstance might appear to create an entirely different counseling situation, Rochelle Cade says much of the counseling process mirrors that used with other addicted clients. Another similarity is that empathy and unconditional positive regard remain crucial to the process, she says.

Cade, a visiting assistant professor at the University of Houston-Victoria who worked with court-mandated clients for five years, often allowed these clients to use the first or second session to “get things off their chest,” she says. Many clients are upset about why and how they were arrested, the court process, their punishment or their perceived treatment by a parole officer, among other things, Cade says. “In my experience, just listening with unconditional positive regard and empathy early in the counseling process is probably the single most effective intervention for establishing the counseling relationship with these clients. I have been told over and over again that no one else — not the arresting officer, attorney, judge, probation officer, family members, friends or bosses — just listens.”

Some people contend that clients who enter counseling of their own free will are more motivated or ready for the counseling process, says Cade, a member of ACA and IAAOC who serves on the editorial board for the Journal of Addictions & Offender Counseling. “Some would prefer that clients enter the counseling process with some insight into the problem or issue or at least have identified the issue for themselves. Court-mandated clients by title and referral do not usually meet these prerequisites for entering counseling.”

Although she uses the phrase “court-mandated,” Cade prefers to think of clients on a continuum of voluntarism rather than of dichotomies such as voluntary/involuntary or mandated/nonmandated. Many clients, not just those who are court-mandated, first come to counseling on the involuntary side of the continuum, she points out. For example, there is the client who goes to counseling because his wife threatens to divorce him or because his boss threatens to fire him if he doesn’t.

Although much of the counseling process is the same, Cade does acknowledge a few unique challenges in working with mandated clients. One is defining the identity of the counselor’s “client.” This most definitely includes the person in the room engaging in the counseling process but might also include the referral source, such as a judge, parole officer or case manager, or other elements of the community. Issues of confidentiality can also arise, she says. “Counselors, with a signed release of information from the client, complete progress reports and submit them to a probation officer, parole officer or case manager, report them to a drug or mental health court, or submit them to an attorney or judge,” Cade explains. “The counselor may abide by the ethical and/or legal parameters of confidentiality in providing these documents, but the recipient of the documents may not.”

Client autonomy can be another sticking point, Cade says, because when clients are referred through the legal system, typically, their “problem” has already been defined for them and the goals of their therapy have been predetermined. Many of Cade’s clients are ordered to participate in substance abuse counseling as a condition of probation for drug-related offenses. “The problem has been defined: marijuana use,” she says. “The goals have been established by the conditions of probation: Submit to urine analyses and have clean results, participate and complete counseling, and abstain from drug use.”

But if clients don’t agree that marijuana use is the problem or decide they’d simply like to decrease their use, that can be out of line with the court’s goals. “I have had several clients who smoked marijuana all day every day decide to cut their use to one joint at night before bed,” Cade says. “Is this reduction in marijuana use [considered] progress? According to the court, it is not. If the results of a urine analysis are positive for TCH, indicating the client is still using, [the court deems this a] lack of progress or failure to abstain from drug use.”

Termination often poses a final hurdle. Cade has had clients participate in counseling for several weeks or even months and then suddenly stop showing up, oftentimes because they’ve been sent to jail for probation violations, new offenses or other reasons. “When the client is incarcerated, the counselor does not have the opportunity to process the closure of counseling and ethically terminate the counseling process with the client,” she says.

Connecting the dots

Considering that people are complex, complicated beings, counselors say it’s not surprising that addictions often coexist with other issues. Certain personality disorders, including antisocial, borderline, narcissistic and dependent personality disorders, seem to have a “robust” connection with addictions, Juhnke says. Anxiety, depression and trauma also commonly accompany addictions, he says.

“Unresolved trauma can be common with many diagnostic subpopulations,” Juhnke says, “For example, I have often found my clients who fulfill Axis II borderline personality disorder have unresolved trauma resulting from sexual abuse or incest, or feelings — real or imagined — of abandonment by significant others. Drinking and drugging behaviors were common ways of attempting to cope with such unresolved or experienced trauma. Thus, asking clients about their history and paying close attention to potential traumatic unresolved issues is important.”

One client told Juhnke that drinking and using drugs were her way of dealing with feelings of abandonment after her ex-husband ran off with a younger woman. “She was able to clearly articulate why and how this unresolved trauma led to her addictive behaviors,” he says. “Removing her addictive behaviors without addressing the underlying trauma would have left her extremely vulnerable. Therefore, it is important to concurrently address any unresolved trauma and addictive behaviors.”

Grief and loss are also significantly interwoven with many addictions, Bates says, whether the losses occurred prior to the addiction beginning, were incurred as a direct result of the addiction or took place during the person’s recovery and set the client back. In circumstances in which clients were using when they experienced a loss, they may not have processed the loss properly and can come to counseling with built-up grief, Bates adds.

Common losses resulting from addictions are wide ranging, Bates says, and can include family, friendships, jobs/careers, freedom, health, finances and educational opportunities. Even in recovery, she says, addicted clients face the likelihood of loss, particularly as it relates to their friends and social identity because, in many cases, those things were tied to the person’s addiction. In losing the old support system, even if it was an unhealthy one, the person faces the daunting task of starting from scratch, Bates says.

“If you take the substance away, you have to reconstruct the identity,” Bates says. “When you have someone who hasn’t really had to form relationships without the presence of a substance, it can be hard to do. You have to relate to the new friends through personality, not through the substance. Sometimes it’s really difficult for people to do. They forget how to behave socially without the drug.”

Other losses that occur while the person is going through recovery, such as the death of a family member or a friend, can trigger a relapse, Bates cautions. Counselors should work with clients on the area of prevention, talking about how they can rebound from losses that might take place while they’re working through recovery.

Grief can also stem from giving up the addiction itself, Fineran says. “The addiction has been their best friend and their coping mechanism. When they give that up, there’s a process of grief they go through [in] reorienting to their lives without it.” Although counselors can focus on many positive aspects of recovery with clients, Fineran says it’s also imperative to recognize what clients might be giving up, such as the sense of comfort the addiction provided them when things weren’t going well and the people, places and things they fondly associate with the addiction.

Working through the grief

No matter what type of loss or when it occurs, Bates says the best thing counselors can do is to address it with addicted clients. Counselors don’t intentionally skip over grief work, she says, but sometimes more pressing concerns pop up in the context of addictions work, such as immediate health, safety and shelter concerns. But whenever possible, Bates suggests, counselors should remember to address losses the client has experienced along the way because those losses might be contributing to or sustaining the addiction. In many cases, she says, grief work enables the client to make better progress in recovery.

Bates says the focus of these interventions should be on recognizing both the positives and the negatives of the losses that addicted clients have experienced. One intervention Bates recommends is writing, whether it involves clients keeping a journal of their feelings and thoughts or writing letters. For instance, clients can write letters to the addictive substance, both ending the relationship and grieving the loss. Or they can write letters to their “using self,” such as “Dear using self, this is why I don’t want to be with you, this is what you took away from me, and this is what I’ll miss about you,” Bates says. A client in early recovery might write to his or her “recovering self,” explaining what he or she is looking forward to in the future.

“It’s really having them acknowledge what things they’re going to miss about the addiction, whether it’s numbing their feelings or feeling high when they need a pick-me-up,” Bates says. “It’s also remembering why we need to get rid of it and why it’s not useful.”

Whereas writing letters encourages clients to take the time to acknowledge both the positives and the negatives of their losses, journaling can help them create a log of their thought processes. Seeing their thoughts on paper aids addicted clients in identifying triggers and patterns they may have been unaware of previously, Bates says — for instance, how having a fight with a parent led to the client using afterward. The client’s journaling can also alert the counselor to grief and loss issues that had not come to light previously.

Another intervention Bates suggests is the creation of memory books, which can take either a positive or a negative focus. A client might make a positive memory book about a loved one who died, including what the client loved about that person, photos of the client and the loved one together and words or pictures cut out of magazines to describe the relationship. Creating the book can help the client process and acknowledge the loss, while memorializing the good things the person contributed to the client’s life.

On the other hand, Bates says, a negative memory book works well for addicted clients who are having a hard time ending their use. These clients might make a book about their addiction, including pictures of doctors or scars or any other bad memories associated with the addiction. “It’s a reminder of why I shouldn’t be using this, even if my body’s telling me I should,” Bates says.

Bates suggests additional techniques that can be helpful to clients dealing with addictions and grief, or addictions alone. Bibliotherapy is effective, she says, as is role-playing in groups, where clients can practice saying no to the addiction or work on new social interactions. Bates also recommends using music to help clients relax and having them draw or paint as a way of sketching out what their lives might look like with or without the addiction. Depending on the individual client’s coping skills, techniques such as guided imagery, meditation and progressive muscle relaxation can offer the client a tangible way of relaxing and regulating his or her body without a substance, Bates says.

Bates also points to Robert Helgoe’s book Hierarchy of Recovery: From Abstinence to Self-Actualization as a good resource for counselors working with addicted clients. Helgoe proposes two phases in recovery: the pull and the push. In the push phase, Bates says, addicts are pushed to remain sober to avoid the consequences of their addiction, such as jail time or liver failure. In the pull phase, the addict is pulled toward a new way of being and enjoying the rewards of recovery. Helgoe’s theory, Bates says, is that to move into the pull phase, a client must first fully grieve the addiction and all the losses associated with it.

Bates says counselors may find it worthwhile to talk with clients about the two phases and what will help them want to stay sober. “Consequences get you [the client] into treatment, but will they keep you here? We have to find something more valuable, and that’s [the client as a person],” she says. “If we can focus on the client as a thing of value, that’s worth working on.”

The spiritual side of addiction

Throughout history, spirituality and addictions have been linked, says Keith Morgen, assistant professor at Centenary College in Hackettstown, N.J., and a member of ACA. Using alcohol as an example, Morgen says that leading up to Prohibition, it was thought that alcoholics didn’t possess any morals, spirituality or godliness. “Addictions were considered as being immoral,” says Morgen, secretary-elect of IAAOC and chair of its Spirituality Committee. “[The thinking was], ‘Because they’re drinking or doing drugs, they’ve turned their backs on society or God.'”

But when Alcoholics Anonymous and the 12-step approach came into being in the 1930s, Morgen says spirituality became a source of strength and comfort for addicted individuals, a way to build themselves back up. “It’s a model for how [those with addictions] can spiritually exist in the world,” he says. The spirituality or higher power invoked in 12-step programs can be a traditional god or any other kind of spiritual, philosophical idea that guides one’s life, Morgen says. “When you do reach that last step, you’re said to have had a spiritual awakening. It’s at the end of the 12 steps, not the start. It helps you get to the point where you’re a spiritual, living member of the world around you.”

Reconnecting spiritually with family, friends, society and oneself is a key piece of the 12-step recovery, Morgen says. “The idea is that your addiction isolates you from the rest of the world. The 12 steps are a road map to get back to the world, the community, the people in your life and also yourself.”

Outside 12-step programs, spirituality can still be a crucial ingredient in the work that counselors do with addicted clients, Morgen says. Tackling spirituality is intimidating to many counselors, so Morgen recommends looking at it from the perspective of how clients see their place in the world — what they value and believe in, what gives them strength and what makes them feel full inside.

Counselors used to try to find out if clients had spirituality as a strength or coping mechanism and then wouldn’t delve any deeper, but they need to do more than simply “check the box” after asking the question, Morgen says. “If you conceptualize it as how [clients] have fulfillment, courage, strength, how they see the world — if all that stuff rolls into spirituality, you almost have to talk about that because that’s who the person is. To try to talk to [clients] about their issues, fears, addictions and trials without talking about values, beliefs, where it comes from, how it has meaning, how it shapes them, it’s almost impossible to do.”

Morgen’s advice to his fellow counselors is to understand that everyone has a different definition of spirituality, and each definition is right for that particular person. Even if clients don’t believe in a god or a higher power, just talking about their philosophical sense of what makes the world spin can be helpful to them, Morgen says.

What benefit can spirituality offer to addicted clients? For one thing, Morgen answers, it provides a point of reference. Many times, he says, in living with an addiction, what addicted individuals do, whom they hurt and what they lose become a blur to them. Spirituality provides these individuals a sense of foundation that they didn’t possess when they were in the throes of the addiction, Morgen says. “It gives you a way to look around and make sense of what’s gained, what’s lost, where you’ve come from, where you’re going and how you fit in to all of that. It gives you an ability to find some kind of meaning, direction and an anchor point.”

Recovery communities

Although popular among many people recovering from addiction, 12-step programs aren’t a perfect fit for everyone, says Gerald Juhnke, professor and doctoral program director in the Department of Counseling at the University of Texas at San Antonio. For clients who don’t connect with the spiritual emphasis of 12-step programs, Juhnke says a number of alternatives exist, including Rational Recovery and Secular Organizations for Sobriety.

Some clients might not be comfortable with the personal interactions that 12-step programs require throughout the various stages of recovery. “If that is the situation, the counselor needs to understand how to get the client the necessary environmental supports without 12-step programs,” says Juhnke, a past president of the International Association of Addictions and Offender Counselors, a division of ACA. “I must say, however, that it is exceptionally difficult to try to recover without changing one’s interactions with current ‘using’ friends. Twelve-step programing immediately provides a group of interpersonal supporters and a social environment where all are in recovery and most, if not all, are very supportive of the client’s personal recovery.”

Although the 12-step approach won’t work for every addicted client, Juhnke says one significant benefit of these programs is that they offer a good mix of people just beginning the recovery process with those who are further down the road. For those just starting out, he says, it can be vital to gain support from more experienced peers, while also being able to look to others for advice and wisdom when relapses occur.

— Lynne Shallcross

ACA addiction resources

The following books can be ordered directly through the ACA online bookstore at counseling.org/publications or by calling 800.422.2648 ext. 222.

  • Developing Clinical Skills for Substance Abuse Counseling (order #72895) by Daniel Yalisove provides a framework for understanding substance abuse and teaches the basic concepts and skills necessary for effective counseling ($29.95 for ACA members; $44.95 for nonmembers).
  • A Contemporary Approach to Substance Abuse and Addiction Counseling: A Counselor’s Guide to Application and Understanding (order #72888) by Ford Brooks and Bill McHenry offers a basic understanding of the nature of substance abuse and addiction, its progression and clinical interventions for college/university, school, and community/mental health agency settings ($35.95 for ACA members; $49.95 for nonmembers).
  • Critical Incidents in Addictions Counseling (order #78058) edited by Virginia A. Kelly and Gerald A. Juhnke explores the opportunities and challenges of working with clients struggling with addiction ($19.95 for ACA members; $24.95 for nonmembers).

Lynne Shallcross is a senior writer for Counseling Today. Contact her at lshallcross@counseling.org.
Letters to the editor: ct@counseling.org

Spotlight on eating disorders

As an assistant professor in the Department of Graduate Education, Leadership & Counseling at Rider University, Juleen Buser’s work focuses on process addictions and, more specifically, eating disorders. Counseling Today asked Buser, president of the International Association of Addictions and Offender Counselors, a division of the American Counseling Association, for her thoughts on the circumstances surrounding eating disorders and possible effective treatments.

Tell us a little about clients with eating disorders. What are they struggling with?

Clients who struggle with eating disorder symptomatology may be struggling with either clinical or subclinical levels of eating disorders. Two major clinical eating disorders include anorexia nervosa and bulimia nervosa.

Anorexia nervosa involves self-starvation behavior, and diagnostic criteria include weight below normal standards and a flawed view of one’s body as overweight. Bulimia nervosa involves binge eating, which is characterized by consuming a large amount of calories in a relatively short time period, a sense of loss of control regarding this food consumption and subsequent compensatory behaviors, such as self-induced vomiting or laxative use. In the new DSM-5 revision, binge eating disorder is planned to be included as a clinical diagnosis. This disorder involves the binge eating behavior of bulimia nervosa but does not include the subsequent compensatory behaviors.

Prevalence rates for clinical eating disorders have been documented to range from approximately 1 percent to 3.5 percent and, overall, are more common among females than males. However, researchers have documented that many more women struggle with subclinical levels of eating disorders — that is, behaviors and attitudes that would not necessarily conform to the criteria for a clinical diagnosis but are nonetheless concerning. Clients struggling with subclinical forms of eatingdisorders may diet frequently, vomit after meals twice a month and engage in a range of other problematic behaviors. Evidence also suggests that subclinical eating disorders can progress to clinical eating disorders. Thus, early intervention efforts on the part of counselors are vital.

Clients who struggle with eating disorder symptoms may engage in their behaviors as a coping strategy. They may utilize, for example, binge eating and purging as a way to manage a range of stressors in their lives — including their distress about their bodies. Interestingly, some research has noted that binge eating and purging behaviors are, in some ways, effective coping strategies, as certain negative emotions have been found to decrease after a binge-purge episode. Yet, other negative emotions, such as shame, have been found to increase after binging and purging. This could be a point of intervention for counselors, who perhaps work from a motivational interviewing perspective and seek to help clients explore ambivalence about treatment.

What techniques are especially helpful?

The field has recommended a multidisciplinary treatment model when working withclients who struggle with eating disorder symptoms. For example, medical professionals are often necessary to assess and monitor the physical health of clients, and working with nutritionists can also be incredibly valuable forclients.

In terms of counseling techniques, therapies such as cognitive behavioral therapy have strong empirical support in the literature. Moreover, authors have also discussed the import of experiential strategies. For example, given that clients who struggle with eating disorders frequently have challenges verbalizing their emotions, art-based techniques can be instrumental in theprocess of accessing and expressing emotional experiences.

Prevention efforts are also crucial. Researchers have documented a range of risk factors for eating disorder development, including dissatisfaction with one’s body and thin-ideal internalization, which refers to an individual’s belief that the thin body shape, often lauded by the media, signifies beauty and is an ideal toward which to strive. Counselors can target these risk factors in prevention programs. For example, some prevention programs introduce the construct of thin-ideal internalization and help clients evaluate this thin ideal and become critical consumers of media messages.

— Lynne Shallcross

Life in transition

Lynne Shallcross

David Fenell has been on both sides of the fence. As a retired colonel and behavioral sciences officer with the U.S. Army and Army Reserve, he has counseled many soldiers returning from deployments on how to fit back in with their families at home. He would advise them to take it slow and to prepare themselves to find that their spouses had changed in some way. “Recognize and value the things he or she has done to keep the home fires burning while you’ve been gone,” he would tell soldiers.

Fenell, who retired in 2009 after 26 years of service, including tours in Afghanistan and Iraq, found it necessary to heed that advice himself when, following a deployment of his own, the transition back home ended up feeling a little less than seamless. While Fenell was deployed, his wife had enrolled in graduate school for counseling. He returned to find that she had turned their house into a quasi-library, with each room serving as a study zone for a particular area of counseling. “I came back home, and the house was completely changed,” says Fenell, interim dean and professor of counselor education in the College of Education at the University of Colorado at Colorado Springs.

Fenell, a member of the American Counseling Association, made a conscious decision to take it slow, respecting what his wife had accomplished while he was gone. But roughly three weeks after his return, nothing had changed, so he broached the subject with his wife. “I don’t feel like there’s really anyplace for me in the house right now,” he told her. “Every room is dedicated to a counseling subject, and it doesn’t feel like home anymore.” His wife quickly moved things around and, before long, Fenell felt like he had a place in the home again.

Fenell’s bumpy transition isn’t unique among those serving in the military, but he was lucky enough to have a counseling background that enabled him to remedy the situation. Those aren’t skills that the average returning soldier possesses. With increased deployments during the past decade, more soldiers are in need of counseling support, Fenell says, and because there aren’t enough military providers to handle the need, referrals to civilian counselors are on the rise.

Lynn Hall, dean of the College of Social Sciences at the University of Phoenix, echoes Fenell, saying that because of today’s extended conflicts, military members are often experiencing multiple deployments. The stress on the family and the couple is greatly enhanced each time a service member is deployed, says Hall, an ACA member who worked for about 10 years as a school counselor in Department of Defense schools in Germany.

The makeup of the military has changed through the years, Hall notes, with more of its members married now than in the past, meaning multiple lives are affected by frequent military moves and deployments. After the change to an all-volunteer military in the 1970s, the military began promising to support military families, Hall says, making it easier for service members to choose the military as a career while still maintaining a family.

In general, according to Hall, military couples marry and have children earlier than civilian couples. Although service members receive the housing, salary and benefits to support a family, the military life often necessitates that these young families move away from extended family, leaving them with less familial support, Hall says. With more military members deploying and leaving their families behind, the need for counseling, including couples and family counseling, is on the rise, says Hall, who wrote Counseling Military Families: What Mental Health Professionals Need to Know, published by Routledge in 2008.

Like Fenell, Hall says more civilian counselors are needed to help military families. The military is stretched too thin to meet the current demand, she says, in part because the military is deploying more mental health workers overseas to be with the troops. In addition, more members of the National Guard and Reserves are deploying. When those individuals return to their civilian lives, they will be more likely to need civilian counselors, Hall says, especially if they don’t have the ongoing support of military resources.

Hall recommends that counselors who want to get connected with military clients contact the family support centers or military mental health providers on local military installations and ask to be added to their referral lists. Counselors can also check with local National Guard or Reserve offices to inquire whether they have referral systems in place. Another option Hall mentions is Give an Hour (giveanhour.org), a program for which counselors can sign up to volunteer their time to work with military families. The program “would be a great way to get in the door,” Hall says.

Fenell also offers ideas for counselors who want to work with military personnel and their families, including reaching out to military chaplains and requesting consideration as a referral source, placing ads in military installation newspapers and informing local Veterans Affairs hospitals and service facilities about their qualifications as counselors.

The significance of couples counseling with military couples shouldn’t be lost on counselors, Fenell says. “It is always a plus for the warrior when he or she is in a stable, loving marriage. It enhances performance in combat or any other military situation. On the other hand, a highly stressful marriage can take the warrior’s focus away from the mission and can lead to problems for the military unit in life-threatening combat situations.”

Culture shock

“There’s a much greater demand for civilian providers, and it’s especially important that they have familiarity with military culture and the things that military couples go through,” Fenell says. Understanding the culture of your client is integral to being an effective multicultural counselor, and the military is most definitely a distinct culture, he emphasizes. Counselors need to connect with clients in ways that validate their culture, their ethnicity and their perspective. In counseling service members and their families, that means letting the clients inform you about their lifestyle, Fenell says.

There seems to be a mentality among service members that civilians don’t understand the military, Hall says. “It could be something as simple as [the counselor] calling an officer by his first name,” she says. “And then the officer says, ‘The counselor doesn’t get it. I don’t want to be here.'” Not understanding the differences between being an officer and being enlisted, not being familiar with military acronyms or not being aware that service members don’t have the power to decide when they’re going to move are common examples of mistakes counselors can make that will turn military clients off from the start, Hall says.

It’s also crucial for counselors to understand and respect the authoritarian structure of the military, Hall says. “As counselors, we’re trained in an egalitarian mentality that everybody in a family should have their rights and everyone should be open to listening and being respectful,” she says. “In a military authoritarian structure, civilian counselors have to put their own values on the shelf and realize that the military has to be the way it is in order to survive, and the couples need to realize that is the culture they live in. They don’t get to make decisions about when they’re going to move or where they’ll live. Their life is regimented.” Within the individual household, a couple can respect each other and care about feelings, Hall says, but it’s important for counselors to understand that the couple’s larger community might not share those same values.

If the nonmilitary spouse is feeling stress from the regimented structure, the counselor can help that spouse express how difficult it is to his or her partner, help the couple respect each other’s feelings and help the struggling spouse to meet his or her own needs within the existing military structure, Hall says.

Fenell concurs that counselors must understand that service members have many of their decisions made for them. Certain decisions are ultimately beyond their control. “There’s a strict protocol in terms of following orders and doing your duty,” he says, “and counselors are more inclined to want to help people find their own solutions and seek the best course of action for themselves. Sometimes, those two dimensions can come into conflict.” Although military values and strict obedience to orders might clash with the values counselors normally support and encourage in their clients, Fenell says it’s necessary for counselors to understand the context of a military couple’s problems in terms of the values they work under.

A certain set of “givens” exists in the military culture, Fenell says, including anything having to do with following direct orders, such as when and where to deploy. “You don’t really have a choice to say, ‘I don’t want to go this time and I think I’ll leave the military now,'” Fenell says. “The goal for the counselor is to help the military member make the best of those givens, finding areas that are not amenable to change and those that are.”

Ever-changing family dynamics

As Fenell experienced firsthand, one of the biggest hurdles for military couples is the change that occurs when a spouse deploys. “I always tell my couples change is ubiquitous,” Fenell says. When spouses deploy, they tend to think their family will remain exactly as it was before they left, he says. “When [the service member] returns, he or she has freeze-framed what it was like prior to the separation, expecting to step into a family dynamic that is unchanged. But it has changed.” If the couple has children, they have grown. The spouse who remained behind has shouldered additional responsibilities and has likely grown into a more autonomous and independent person as well, Fenell says.

He recommends that counselors encourage the couple to identify the changes that have taken place. It’s often the case that both spouses have changed, Fenell points outs, even though each partner is more likely to notice only the changes in the other person. It helps to have the couple discuss how things played out during the deployment, how responsibilities shifted and how they can renegotiate the division of labor, he says. One area in which problems can arise is when one spouse has grown more autonomous and the other feels threatened by that development. When this happens, Fenell says the counselor should help the threatened spouse recognize that the relationship is evolving, becoming more healthy and less dependent. Having a service member return and automatically expect the spouse to give up all the duties he or she was shouldering, essentially relegating the person to a subservient role in the relationship, is not ideal, Fenell says. “Giving up autonomy is not a recipe for a good marriage.”

The transitioning of one spouse out of and then back into the household can be extremely stressful, Hall says. When one spouse leaves, the remaining spouse and their children learn to function as a single-parent household. But when the soldier returns, all roles and responsibilities must be shifted again. In some cases, the returning spouse expects to take over right away. “Family members think, ‘Hey, wait a minute. I did this job for nine months. Why are you now telling me what to do?'” Hall says. In other cases, service members are unable to help pick up the slack at home because they are still overwhelmed by what they experienced during their deployment. This can also heighten tension in the home.

Part of the solution is for counselors to help each person understand the other person’s perspective, Hall says. The spouse who remained behind might think he or she has done a great job running certain aspects of the household and could be reluctant to surrender those duties now that the service member is home. On the other hand, Hall says, the service member needs to feel that he or she can contribute to the household again. “Get both people to hear the other person’s side,” she says, “and then start making some reasonable accommodations to get the service member back involved in the household without the spouse feeling like she’s giving up everything.”

There are also instances in which the spouse who stayed behind makes it known that she or he can’t take another deployment, Fenell says. If the service member doesn’t want to consider giving up a military career, the circumstances can turn into a major roadblock for the couple. “One of the things you try to discover in working with the couple is whether it’s more than ‘I just can’t do it anymore,'” Fenell says. For example, he says, the spouse might feel overwhelmed by the prospect of handling the kids again solo while the military member is deployed. In that case, he says, helping the spouse determine ways to secure more support in caring for the children during the next deployment might offer a possible solution. “But if it’s pure ‘I can’t do it again, and I won’t,’ and the warrior won’t leave the military, then you can help them disengage in ways that are least damaging to themselves and to the kids. Make [the split] as amicable as possible.”

In many cases, Fenell points out, when the nondeployed spouse is doing well during the deployment, the kids are also managing well. But when the spouse is feeling stressed out and overwhelmed, the kids pick up on that and might start struggling, too. The family’s anxiety can transfer to the deployed service member as well, Fenell says, creating extra difficulty in the combat situation. He believes the best-case scenario is to encourage the nondeployed spouse and children to seek counseling during the service member’s deployment. This offers them a sense of stability, an outlet where their concerns can be heard and a place to receive concrete suggestions for overcoming life’s challenges as well as assistance in finding additional support systems.

On a different front, combat stress is something that can and often does return home with soldiers, Fenell says. But in his opinion, post-traumatic stress disorder is being overdiagnosed among returning military members. “Many returning veterans do have some symptoms. However, most are having normal reactions to very abnormal circumstances,” he says.

If everyone, from society at large down to the service members’ military units and families, treats them as if they are “damaged goods,” then the service members are going to have a more difficult time recovering, Fenell says. But if the culture, the military and the service members’ families come to perceive these symptoms as a normal reaction to the stressors of combat, “they’re creating a context for healing rather than a culture that pathologizes,” he explains. Counselors with expertise in trauma therapy might be especially well equipped to help military couples navigate this healing process, he says.

Beyond deployments, Hall says the repeated transitions military families must face in getting reassigned and moving every few years can place a strain on them and make them feel as though they don’t fit in with the way the rest of the world works. When people don’t possess a feeling of belonging, Hall says, they often end up feeling ” less than.” Her recommendation to counselors is to assist these families in acknowledging some of the positive aspects of being involved in the military as well as ways the experience has made them stronger.

At the same time, Hall says, it’s equally important to address the grief that accompanies a life of constant transition, which includes saying goodbye to friends, family members and even pets. “The military mentality is that you move on and you don’t worry about it,” Hall says. “You’re not allowed to grieve.” But working with military families means allowing them — giving them — that space to acknowledge what they are leaving behind and what they will miss. That is an important piece in helping these families make healthy transitions, Hall says.

The right approach

When working with military couples, Fenell says basic counseling techniques such as establishing a healthy relationship based on trust and reflecting each person’s perspective can go a long way. “A skillful therapist can connect with both partners in each person’s own way without feeling more of an inclination [that] one person is right and one is wrong,” he says. “Once they see you’re going to be objective, they’ll trust you more.”

Family therapy can be helpful in letting the counselor experience firsthand how the family interacts and attempts to solve its own issues, Fenell says. This approach also allows the counselor an opportunity to normalize the reconnecting process in situations in which a spouse is returning from a deployment and trying to bond with the children.

In terms of specific counseling techniques, both Hall and Fenell agree that going straight for the couple’s feelings isn’t the best approach. “Military men are trained right from the beginning that they’re not supposed to acknowledge their feelings,” Hall says. “If we go there first, we’re basically going to lose them.”

“We want to get in touch with thinking in the realms of ‘What do you believe about this? What do you believe that relationships should look like? Where did you learn that? What do you think you could change that might make a difference?’ If we’re lucky,” Hall continues, “we’ll be with them long enough that we’ll get to the emotional piece. But first, focus on what the military focuses on: ‘What are the goals? What do I have to change about my thinking or attitude? And how do I change my behavior in order to reach my goals?'”

A cognitive behavioral approach works well with military clients, Hall says, as does solution-focused therapy and Adlerian techniques. With this particular population, Hall is a proponent of reducing the chaos and finding ways to get problems resolved in a timely manner. “We need to get in and help them make a change quickly. If we do, then they’ll probably come back,” she says. Hall adds that because of the ongoing cycle of relocations and deployments, the “next session” is never a guarantee with military clients. For that reason, counselors should focus on being goal oriented in each session, she says.

Fenell agrees that a cognitive behavioral approach is a good starting point with military families. As the counseling relationship grows and the couple learns to trust the counselor more, he says the counselor might move into more affective approaches. When appropriate, Fenell recommends emotionally focused couples therapy because it is grounded in a systemic viewpoint, recognizes healthy dependence as a strength and helps couples affectively tap into feelings present in the relationship. Structural family therapy is another technique to which a military mind-set might more readily relate, Fenell says.

Guiding a struggling military couple to retrace why they selected each other as mates can also prove fruitful, Fenell says. The counselor can help the couple review what attracted them to each other, what values they had in common and why they bonded, with the goal of enabling them to build on that foundation moving forward.

Hall says that when she worked in the overseas schools, military families often came to her looking for concrete answers and solutions to their problems. Befitting the authoritarian structure of the military, these families pledged that if she simply would tell them what to do, they would do it. “If we as counselors buy into that and it doesn’t work, then we’re the bad guys,” she warns. Instead, Hall recommends turning the situation around and helping these clients explore for themselves what solutions might work within the military structure in which they operate as well as within their own families. “We can give them some things to consider or help them look for the consequences of each one of their actions,” she says, “but we’re probably not doing anyone a favor by saying, ‘Here’s the answer.'”

Beyond the counseling sessions, Hall advises that counselors stay on top of other resources in the community and promote their availability to military clients. Many military installations have family support centers, support mechanisms for families going through a deployment and even career counselors, but military members aren’t always aware of these tools, she says.

Civilian counselors should understand ahead of time that military couples are unlikely to look like or interact like civilian couples, Hall says, regardless of the specific problem that has brought them to counseling. “We’re not trying to take them to a place where they can sit down and make decisions about whether they’re going to move to a new community or not,” she says. “Hopefully we can get them to make decisions as to how they raise their kids or spend their money, but you always have to help them understand that it’s within the military structure.”

Lynne Shallcross is a senior writer for Counseling Today. Contact her at lshallcross@counseling.org.

Letters to the editor: ct@counseling.org


Navigating life’s learning curve

Lynne Shallcross May 1, 2011

Picture this: You’re a college student cramming for finals in a campus lab late one Sunday night when you see a lanky, 6-foot-2-inch, long-haired man striding toward you wearing a red polka-dotted hat and carrying a tower of pizza boxes. You could be excused for thinking you’ve ingested one too many cups of coffee and that you’re finally hallucinating. But if you’re a student at the Savannah College of Art and Design (SCAD), you shriek with delight because the Pizza Fairy has arrived.

“We thought you were just an urban legend!” students tell Pat Mooney, who takes “flight” as the Pizza Fairy three times a year. Otherwise, Mooney can be found working as a counselor with SCAD’s Counseling and Student Support Services. Though slightly nontraditional, the Pizza Fairy is one of the counseling center’s most effective outreach initiatives.

Because SCAD is an art school, many of its students can’t sit in the comfort of their dorm rooms to study and complete projects, Mooney explains. This leaves them up late at night working in buildings spread across campus. So at 11:30 on the Sunday night before finals, Mooney hops in his van, picks up 73 large pizzas and distributes them to hundreds of lucky (and overworked) students. For every group of roughly 10 students that Mooney comes across, he delivers a pizza as well as a flier that reads, “You have been visited by the Pizza Fairy, whose motto is, ‘The road to good mental health is paved with pizza!'” The flier also contains information about how to access SCAD’s counseling services.

Mooney says the director of the counseling center first proposed the idea of taking pizza to studying students approximately seven years ago. When Mooney, a member of the American Counseling Association, volunteered for the job, he decided to make the outreach effort a little more fun, and soon it morphed into the Pizza Fairy concept. In retrospect, pizza turned out to be a wise choice, says Mooney, who notes that the “Arugula Fairy” probably wouldn’t possess the same cachet. “We [the counseling center] also sponsor Donut Divas, who do their thing in the morning,” he adds. “Some other departments, such as residence life, have picked up on the concept and take other kinds of snack foods around on nights when the Pizza Fairy is sleeping.”

But if the local Pizza Hut delivers, why does Mooney go to all that trouble? For one thing, Mooney says, it’s fun and uplifting, both for the students and for him personally. Delivered in this way, the pizza also seems to entice the students away from their computers, even if only for a few minutes, to talk with their peers and to feel a sense of connection. But the larger goal of the initiative, Mooney says, is to reach out to the campus community and remove the stigma of utilizing the counseling center.

“For years, various agencies and organizations have been making efforts to ‘destigmatize mental illness,'” says Mooney, who is also a member of the American College Counseling Association, a division of ACA. “We didn’t feel that quite hit the mark in terms of the message we wanted to get out. Though destigmatizing mental illness is certainly a good thing to work toward, we felt that there was a certain stigma to even coming to the counseling center or seeking therapy in the first place. That’s what we began to focus on in our discussions of how best to serve our students, and the nature of our outreach changed as a result.”

SCAD’s counselors still engage in many traditional outreach activities, such as depression, anxiety and eating disorder screenings, Mooney says, but they try to focus even more on fun activities. “We want to connect with students in such a way that if they run into problems that they’re having trouble solving utilizing their regular resources, they’ll think of us and not hesitate to contact us. We take great pains to not have a waiting list and to be a resource 24/7/365. Our sense is that in terms of service to the SCAD community, we’re able to do a better job because more students come to us before things get out of hand.”

When students get help early on, it might help them head off larger problems down the road, Mooney says. “People will try to solve their own problems, but when that begins not to work, we want folks to see us not as a place of last resort, but as a first stop. If they come to us initially, we might be able to prevent further deterioration.”

New low for mental wellness

Nationwide, more pizza fairies might be needed. A recent study by the Higher Education Research Institute at the University of California, Los Angeles puts the emotional health of college freshmen at its lowest level in 25 years. “The American Freshman: National Norms Fall 2010″ surveyed more than 200,000 full-time students at four-year colleges and universities and found that the number of students who reported their emotional health as above average had declined 3.4 percent since 2009 and 11.7 percent since the survey began tracking emotional health in 1985.

The survey’s results are on par with what many college counselors are seeing on their own campuses. Although Central Wyoming College’s once-rising enrollment leveled off for the first time in four years this year, Lance Goede, director of counseling and career services at the two-year community college, says his caseload has almost doubled. Meanwhile, at SCAD, Mooney and his colleagues have had conversations about how stressed the students seem in comparison with past years.

The economy is one likely factor, Mooney says. “Not only is the current situation with many students and their families stressful, [but] the prospects for new grads aren’t as rosy as they have been in the past. More students are having to work at jobs” — in addition to attending school — “and work longer hours to make ends meet, expenses are rising, family economic support is dwindling, competition for jobs is increasing and so on.”

“Consequently,” Mooney continues, “I think it’s more important than ever to help our students develop life skills that will serve them well when the chips are down. Deliberately paying attention to and acting in ways that promote good mental and physical health is important. Being able to think and solve problems creatively and with flexibility is useful, as is being able to collaborate, connect and network. Being able to tap into and maximize personal assets while compensating for deficits is helpful, too.”

ACCA President Brian Van Brunt agrees that the economy is a major factor in increased stress on campus. “Many college students are struggling with the idea of college being worth the investment on the other end,” says Van Brunt, who serves as director of counseling and testing at Western Kentucky University. “I think they often worry about having a job after college and if spending upward of $30,000 on a college education is something they will earn back over time. This can be particularly difficult for students who are watching their friends enter the workforce after high school and earning a paycheck while they are saving and working their way through college.”

But an alternative way of looking at the results of “The American Freshman” study, Van Brunt says, is that school counselors have grown more effective at supporting students in high school, enabling struggling students who wouldn’t have gone to college in the past to now achieve that goal. “We’ve supported more at-risk students to reach for college in ways they never have before,” he says. “Part of why they’re struggling [in college] is because they’re reaching higher than they have in the past.”

At Central Wyoming College, the student population is split equally between traditional students and those returning to school at a later age. Goede, a member of ACA and ACCA, has noticed an increase in students coming to campus with learning disabilities, particularly straight out of high school. He acknowledges there is a push in high schools to give students as many options as possible. Adding to that, Goede says, Wyoming has an open-door policy dictating that state community colleges must admit any Wyoming high school graduate who applies.

When students aren’t properly prepared to meet the demands of college classes, it leads to a buildup of stress and frustration, Goede says. To help alleviate that, Goede works in conjunction with disability services to assist struggling students. He also offers career counseling services so students are aware of their choices. For instance, if a particular student is focusing on a career that requires calculus but is struggling with basic math, Goede helps the student look at alternatives and set realistic goals.

Age-old issues

Looking beyond the economy and learning disabilities, counselors say the issues college students bring with them to the counseling center run the gamut. According to Van Brunt, some of the most prominent issues tend to be depression, anxiety, relationship problems and academic stress. “I think the age-old problems of school are still first and foremost on college students’ minds,” he says. “They worry about paying for college, about trying to [strike] a balance between finding enough time to study and to have fun, and there is that old fear of finding Mr. or Mrs. Right. While many of the ways college students experience stress have changed” — for instance, having to decide whether to invest in a life coach to choose a college, being bombarded with marketing from different schools and dealing with the added pressures of social media — “the underlying issues remain the same.”

In his experience at SCAD, Mooney has found that certain issues seem to ebb and flow throughout the year. For instance, in the fall, there’s a fair amount of homesickness and anxiety over time management and balancing the workload. In the second quarter, students aren’t generally as anxious about the adjustment, but the winter blues can set in. Mooney also points out that many mental disorders, such as bipolar disorder, schizophrenia and depression, often rear their heads during the college years and begin to interfere with daily functioning. There are various ideas about why this happens, Mooney says, but it’s one of the reasons they encourage students not to wait until things get dire before coming to the counseling center.

In Wyoming, Goede has noticed a consistent theme regardless of the students’ ages: relationship problems. “There’s a lack of communication between husbands and wives, boyfriends and girlfriends,” he says. “It seems like everything goes to an argument. Everything goes to an emotional response.”

Goede consistently hears from his student clients that they tend to react emotionally rather than analyzing the issue and considering how best to communicate. While the younger students sometimes have yet to develop more mature communication skills, the older students often need a refresher on those skills as well, he says. When Goede sits down with clients to help them analyze their situations, they often have “aha” moments in which they recognize that their significant others might have responded on the basis of something they said or didn’t say. “More than anything, it’s getting them to talk about what they are doing and giving them some insights about other ways to think about things or act,” Goede says.

College students experiencing relationship problems might not be aware there are options beyond yelling or making sarcastic remarks, Goede says, so he works with them to come up with other ways of reacting and then asks them to test drive these alternatives as homework. He says cognitive approaches can be effective in helping student clients analyze their thinking patterns, identify where they got off on the wrong track and see how they ended with an emotional rather than a rational reaction.

A fair number of Goede’s clients present with substance abuse issues. Many of these students are referred to him after violating rules in campus housing. Most of the issues stem from alcohol abuse, and Goede acknowledges it’s sometimes a matter of kids simply being away from home and pushing the boundaries. “But it’s definitely impacting their schooling,” he says. “There are definitely effects of substance abuse on their success.”

When students are referred to his office, Goede often uses one of two programs — eCheckup to Go (e-CHUG), an online program in which students answer a variety of questions and the program reports back on the physiological and mental health effects of alcohol on their lives, or Choices, a journaling program that helps students analyze how their behavior is affecting them personally. Both programs also include statistics that can help students realize they are in the minority as heavy drinkers, not the majority, Goede says.

A safe place

Heading off to college is a pivotal point in many people’s lives, and the nature of the transition can introduce or magnify issues of adjustment as young people reach independence and adulthood, Van Brunt says. The larger philosophical questions of “Who am I?” and “What am I living for?” often take center stage. “This transition phase from ages 18 to 22 is a significant one full of energy, questions, struggles and potential pitfalls — suicide, alcohol and drug problems, and balancing work and social needs,” Van Brunt says. “As with a young child, problems left untreated and needs left unmet can lead to lifelong difficulties in relationships and playing catch-up in certain developmental areas. College students are similar. Powerful relationship losses, abuse of alcohol and drugs and lack of hope and meaning during these developmental years can lead to cyclical broken ways of interacting with others and creating a happy life. College counselors are in a unique position to smooth over some of these rough spots, keep problems in perspective and, most important, inspire hope for a brighter tomorrow when things may look dark and without purpose.”

The counselor’s office should serve as a place where students can vent their frustrations and express their worries and fears about the future, Van Brunt says. “We help them place their concerns in a normative context, can often help reframe problems so they seem less overwhelming and assist students in obtaining a foothold to begin their climb out of the hole they find themselves in,” he says. “College counselors also offer direction and guidance in terms of managing stress, making decisions about medication and how to best manage symptoms of mental illness. Mostly though, we provide a caring, nonjudgmental place to work on their problems and worries. We listen, we care and we offer them support.”

At SCAD, Mooney works as a solution-focused therapist, which he says is particularly well suited to college students. Oftentimes, students actively want to solve their own problems, he explains, and solution-focused methods build on the assets they already possess. Mooney says he often can tell within the first five minutes of talking with student clients which of their skills will help them most in solving their problem.

In the case of one recent client, the solution was hidden in his athletic experience. The student came to Mooney expressing anxiety about the speech class he was required to take. He was very tall, a little self-conscious, and he would lose focus speaking in front of groups and end up talking in circles. Mooney asked the student a little more about himself and found out he was a swimmer.

Mooney told the student to imagine the moderate level of anxiety he might feel before a swim meet as opposed to the high level of anxiety he was experiencing before a speech. Mooney then encouraged him to try to plateau at that moderate state before a speech. Next, Mooney talked about how the student swam laps at meets and how he could use that concept to structure his speeches into a sequence rather than talking in circles. By working with Mooney and building on his existing skills, the student learned to manage his anxiety and went on to earn a good grade in the speech class.

Motivational interviewing (MI) and motivational enhancement therapy (MET) also tend to work well with college populations, Van Brunt says. “These approaches start with a therapist working with a student where they are and trying to help through harm reduction strategies. For example, if a student comes in and wants to cut back [his or her] drinking, an MI or MET therapist would start with where the student is currently drinking and help look at ways to cut back slowly. They would not frustrate or challenge the student but instead roll with any resistance and find ways to support the student’s successes and overcome any obstacles.”

Another of Van Brunt’s favorite tools is the humanistic existential approach to therapy. “Here, the therapist takes a stance related to the students’ humanity and essential ability to face obstacles and overcome challenges. The therapist engages students through rapport building, supports their choices and creates a safe place for them to explore and wrestle with dilemmas they may be struggling with.”

Van Brunt offers the example of one of his clients who has faced multiple suicide attempts, difficulties with her family and early childhood trauma. “Many think she doesn’t have what it takes to be successful on campus,” he says. “[But] home is worse for her, offering little support, and will likely lead to the worsening of her illness. The hospital holds no answers for her — she is in and out several times a semester. Her medications help stabilize her but don’t fix the underlying problem.”

As her counselor, Van Brunt focuses on giving her a place where she feels cared about and secure enough to talk. He advocates for her with different groups on campus, assists her with academic requests for accommodations on the basis of her illness and interacts with the conduct office on her behalf. “I help by giving her a stable, consistent place to come and talk when she needs to,” Van Brunt says. “This simple caring and understanding — and, dare I say, love — is what many college students are looking for. Therapy provides them a place to work through their problems in a nonjudgmental atmosphere with a therapist whose main goal is to help them feel more balance and peace in their lives.”

It’s important for college counselors to be broadly knowledgeable in varied techniques, Mooney says, because while cognitive behavior therapy might help with one student client, another might call for family systems or object relations work. “The thing that is key in my mind is that you tailor the approach to what the student needs,” he says. It’s important to skip a pathology-based focus, Mooney emphasizes, so that no matter what techniques counselors use, they look at the glass as being half full and focus on the client’s assets.

Van Brunt offers similar words of wisdom to counselors working with college students. “The main advice I would give is the importance of not overpathologizing problems that may be environmental and contextual in nature,” he says. “Many of the issues we see students for are related to struggles they are having with the normal, developmental adjustments to life away from home and moving toward independence.”

Van Brunt also acknowledges that college counselors will inevitably encounter more serious mental health problems that might require assessment, medication and ongoing treatment. In those cases, he says, it’s important to offer the same type of supportive and nurturing care and to understand that these students are often scared. Says Van Brunt, “Counselors and psychologists should always offer hope — the promise that tomorrow will be better.”

To see a video of the Pizza Fairy in action, visit http://vimeo.com/20717590.

Lynne Shallcross is a senior writer for Counseling Today. Contact her at lshallcross@counseling.org.

Letters to the editor: ct@counseling.org