Tag Archives: Counselors

Growing up: An allegory

By Shawn Patrick September 15, 2016

When I turned 39, I had a midlife crisis. I wasn’t home on my 39th birthday. I was on another continent, sitting in a hotel lobby at stupid early o’clock, jet-lagged and writing because I couldn’t sleep. I looked up, saw the date and realized my birthday had occurred while I had been traveling, the day lost somewhere in the time vortex that opens up when flying overseas. Technically, then, it was the day after my 39th birthday when The Voice screamed at me, “What have you been doing with your life???!”

Granted, I had earned a doctorate, had achieved tenure, had published manuscripts. I had two lovely children, and I had managed to stay married to the same person longer than any other person in his or my family history. These are not small accomplishments. But this is not what occurred to me in that panic-inducing moment. Rather, The Voice pummeled:

“Why aren’t you on The New York Times’ best-seller list yet? What happened to the blockbuster movie? Where is the Fields Medal? Why haven’t you played Carnegie Hall yet? You haven’t even photo-1458175049065-aefb15b1b58bbothered to figure out the grand unification theory bringing together quantum mechanics and the theory of relativity — you’ve been sitting back letting Stephen Hawking do all the work. What the &$@# is wrong with you?”

Part of the problem for those like me is that we still cling to our childhood fantasies of success. We grew up imagining ourselves getting discovered simply because Hollywood Movie Mogul in a red convertible Mercedes screeches to a halt while we’re walking down the street and shouts, “There, there is the person I’ve been waiting for!” And the other part is because we were given some remarkably confusing aspirational advice.

In grade school, I was in the first group of identified “gifted” children. I didn’t know what it meant, and no one else understood it either. But to the dozen of us who were selected, it meant that we could leave class a few hours each week and play games. This was a good deal in our opinion, so we didn’t question anything. Yet without our knowing, we were already receiving those sneaky messages about where our lives were supposed to end up.

The social strata are well-established by high school, telling us who is and is not supposed to be a productive member of society. We instinctively knew there were no real differences between these arbitrary groups; the “achieving” group could simply get away with more because no one expected us to do anything illicit. The “remedial” group included plenty of individuals who were extremely smart and capable, but for reasons well outside themselves, no one paid attention to them anymore. This stratification persisted due to factors outside our control and taught us about the many forms of privilege and its consequences.

Many of us slowly go insane from pressure to climb to the top of the mountain, to win, to be the best at whatever is deemed successful. If we don’t accomplish it, then we have let the whole of civilized society down, our ancestors are forever shamed, and our future offspring will only hope to dream about peeking through the window of a good school. Include the discourses bombarding teenagers about being “Someone” — e.g., a doctor is better than a nurse, a scientist is better than an artist, a rich person is better than a poor person. So often our legacies make no sense to us. We are pushed by unexplained, invisible forces, but if we make a mistake, we will ultimately carry all the blame for what goes wrong. Everyone loves to claim the credit when someone succeeds, but if that person fails, it’s all on you, baby.

I never knew what I wanted to do. When I graduated high school, I had one very well-meaning teacher give me the kiss of death. I experienced heart-palpitating conflict over choosing a college major. Enter this literature teacher who took great interest in my writing. At the end of the term, I asked him to sign my yearbook. He wrote:

“Good luck to you in all you do. I know you’ll go far. Keep writing because it’s clearly what you were meant to do. Of course the last person I said that to now only writes grocery lists. Best wishes, B.”

He had a genuine interest in my future, and I suspect he thought he was being funny. But he had no idea how this gong resonated throughout my core, highlighting the double bind I lived with: You can do anything you want, but what you want might not amount to anything.

When I turned 39 in a hotel lobby, all I’d really figured out was that in one year I’d be 40. What did I have to show for myself? Had I even come close to approaching some of the lofty aspirations I held for myself, or did I too end up writing grocery lists?

Part of maturity is realizing that the frenetic pace of youth cannot be maintained. Eventually, we have to abandon the immature need for immediate gratification. Recognizing our mortality means catching on to the idea that one is not interested in dying due to blowing out your own candle; death will come in its own time, so why not learn to live? These are the chronic existential conversations that infiltrated my head as an adult who had to concern herself with things like paying bills. And the appearance of children completely redesigns the landscape — a total home renovation that leaves you forever wondering where you left your keys. So pacing becomes a necessity. Priorities must occur because we are forced to write our own instruction manuals for adulthood.

But the adult dilemma becomes, did I pace myself too much? Did I slow down to the point of stopping? Specialization is an ironic creature. It is comforting to think you actually know something. However, the danger in such comfort is that it can easily lull you into complacency. Did I avoid the new thing because I didn’t have the time, or because it would mean stepping outside of what was familiar? In the guise of developing “expertise,” did I actually limit myself from gaining knowledge?

“How have you made your mark on the world?” Regardless of how far-fetched, lofty, idealistic or fantastic my earlier aspirations were, they were there to tell me to make more of myself. Not in the sense of being the best, biggest, brightest or richest, but in the way of being more than just what was prescribed for me. Have I challenged myself? Have I at least tried to take a risk, or do I still play it safe? Did I keep listening to what everyone else demanded for my life, or did I speak up and say, “Here I am, like it or lump it.”

Disturbingly, my answer at age 39 was, “Well, sort of.” In examining how I had established myself, I found that even though I wasn’t writing grocery lists, I hadn’t exactly written sonnets either. Perhaps I felt like something was missing because something was, indeed, missing. Perhaps I was being told it was time to take the next step. I had allowed myself to live with a list of “what if” questions — What if I’d done this? What if I had gone there? What if I were like that? — and I’d fallen into the trap of constant speculation. Everyone wants to be Yoda, but I was at risk of turning into nothing more than Super Grover stuck in a tree.

I didn’t know what my mark would look like, but I decided I could live as though I had made one and see what happens. I stopped saying “no” and started saying “yes.” That’s not to say that I suddenly started agreeing indiscriminately with some “you can do anything” illusion. Instead, I decided that fear or social disapproval would no longer be enough of a reason to prevent me from trying the new thing. “It’s the way it has always been done” was no longer a good enough reason to stay the same. Not knowing became the reason for acting.

Experiments in living can have curious effects. All kinds of wild ideas entered my mind. Not all were viable, but the energy that comes from rediscovering one’s creative power is intoxicating. It flows into every part of work and life.

If this were a fairy tale, I would stop at this “happy ending.” But I’m not trying to wrap my experience up in a neat bow, nor am I trying to say that this is just my story. I’m not 39 anymore. I’ve had a few years to live with my experiment, and I prefer living this way. But it has not made life easier. In fact, living as though the “what if” has already been answered makes life more challenging. But it’s a challenge I put to others — and especially to a counseling profession that also seem to have gotten stalled in its own internal-gazing.

Twenty years ago during my master’s program, my professors said that counseling was in its adolescence. Today, we are still struggling with questions of identity. Who are we? What are we about? What do we believe in and stand for?

We have gone through several fast-paced movements, some which have enhanced us and some of which have diminished us. Like so many tumultuous progressions, we regularly take three steps forward and two steps back. Yet we also seem to have lulled ourselves into a strange quietude, the kind where we exude certainty until we are asked to define what it means to carry this mantle. In our quest for legitimacy, we could very well have sold ourselves out, making us into a caricature of the professions we seem to think we should be. Are there lessons we can borrow from fields such as psychology, social work or psychiatry? Certainly. But at what point do we stop saying, “This is who we are not” and instead assert, “This is who we are?”

The “what ifs” have caught us for far too long. How many debates, circular arguments really, do we get into about which theory is the “best,” which specialty is the most important, who is the most moral or just? At what point will we admit to ourselves and the rest of the public how many of our choices have been profit driven — claims staked to promote our own brand of job security? What do our politics really say about us — not an individual’s personal views, but the fact that we as a profession still argue amongst ourselves about who is granted personhood.

What if instead of fighting over limited crumbs, we acted like a profession with a unified vision, not of what each counselor should do but of who our profession is meant to serve? What if we stopped proving our legitimacy through purely Cartesian lenses and instead recognized that the totality of our work cannot be reduced to widgets and Facebook memes but must also encompass a marvelous, mysterious human interaction? What if instead of resting on our certainties, we asked ourselves in what ways our insecurities have seduced us into believing that the illusions we cling to are the realities that everyone must follow? What if instead of being afraid of our differences, we took a chance to allow ourselves to be influenced by each other in the ways in which we arrogantly expect our clients to be influenced by us?

Prepare to grow up, Counseling. What have you been doing with your life?




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



Shawn Patrick is an associate professor in the counseling and guidance program at California State University, San Bernardino. Contact her at shawn.patrick@csusb.edu.



Don’t use the ‘t’ word and five other tips for counselor advocacy

By Kevin Doyle March 29, 2016

After 30 years in the counseling profession, I have arrived at the conclusion that we counselors are sometimes our own worst enemies. When a unified voice could be the key to advancing our profession — such as with current efforts to expand reimbursement for counselors’ services under Medicare, initiatives to standardize our licensing standards and outreach to get more counselors Branding-Images_Avocacyhired to positions within the Department of Veterans Affairs — we at times seem to be fighting our own internal battles instead.

How, then, can the individual counselor do his or her part to advance the profession that we all love? In the spirit of helping the counseling profession achieve the status that 40 years of licensure would indicate, I’d like to offer six concrete, yet relatively simple, suggestions.


First, as my students would corroborate, I have a visceral resistance to using what I call the “t” word: therapist. Although probably well-meaning in most instances, when counselors use this word, they miss opportunities to use an even better one: counselor. The same principle exists for use of the word therapy when counseling could be used.

In our culture, most people do not know the differences between counselors, social workers, psychologists and even psychiatrists. Each time that we call ourselves by the correct name (counselor), we are taking advantage of an opportunity to educate the public about our profession — to help with our own branding, if you will. Similarly, each time that we use therapist or therapy, we are missing out on that same opportunity and in a small way contributing to the ongoing diminution of our professional identity. When referring to a multidisciplinary group of helping professionals, using therapy or therapists is, of course, appropriate.

A second concrete action that each of us can take is to refer to other counselors. Obviously, our primary obligation is to our clients, and if the appropriate and best referral is to a helping professional in one of our sister professions, then so be it. But in making referrals, we are afforded another opportunity to help our profession advance, so we should include professional counselors as often as possible when we refer.

In my hometown of Charlottesville, Virginia, several licensed professional counselors got together a few years ago and formed a loosely organized group. We meet monthly for informal support and discussion and engage in quarterly trainings together for required continuing education. But in addition, we have also established an active professional network that has allowed us to learn more about the expertise of local counselors, which has greatly enhanced our ability to make appropriate referrals. Rarely does a week go by without a member of our group posting a message to our distribution list asking for help in identifying a fellow counselor to work with a particular type of client. Referring to other counselors, when appropriate, is one of the best ways that each of us can support our profession.

My third suggestion relates to the electronic age in which we currently operate. We must not underestimate the power of the Internet. Unfortunately, many counselors in our community do not have websites, so the referral process I outlined above is often complicated by the fact that most clients want to read about the person they were referred to before pursuing services with that professional. Because of that, we may be forced to refer to a professional from another discipline who does maintain a website. Lest counselors be discouraged by expense, several low-cost or even free web-design templates are available (for example, see weebly.com, wix.com and web.com). Using these or other templates, the main cost involves purchasing the domain name and hosting the site, which is typically quite affordable (often less than $100 per year). In addition to generating referrals for your practice, having a website helps to solidify the presence of counselors on the Internet and further legitimizes our profession in the eyes of the public.

A fourth step in advocating for our profession induces fear in some counselors and may not be for everyone: talking to the media. Local newspapers, radio stations and television outlets are on a continuous quest for fresh content related to issues of the day. Some counselors routinely turn these requests down (I know, because they refer the media to me), missing another chance to educate the public about themselves and the profession.

Dealing with the media can be tricky, of course, but simply discussing what our profession does can be a valuable public service and an opportunity to teach about what counselors do. Commenting on particular cases or specific clients would be problematic and even potentially unethical, but participating in an interview on a particular issue, such as a counseling approach, what counselors do or a topic of interest to the local community, could be entirely appropriate and valuable. American Counseling Association staff members are available for consultation on talking to the media as well.

Getting to know your state and local legislators is a fifth way for counselors to engage in advocacy for the profession. State legislatures vary greatly, but most are composed of part-time legislators who spend much of their time in their local communities. These legislators are almost always extremely open to meeting with constituents (another word for voters!). Waiting until an issue is in front of the legislature to visit with your elected representative is often too late. By that time, whatever opposition exists may have already made its position known, meaning you may be up against a formidable adversary in a politically charged environment. A better approach is to proactively establish a relationship with local legislators. This can be done by inviting them to visit the program where you work, introducing them to other counselors, considering honoring them for work they may have done that is helpful to your clients or considering making a campaign contribution. Any or all of these steps can make a real difference when counselors in your state legitimately need the help of the legislator on a particular issue.

If you are uncomfortable or overwhelmed with the idea of visiting your local legislator, think about going as a group. Several counselors, perhaps with different specialties, can attend a meeting together, allowing the elected official to learn from multiple perspectives on a single visit and maximizing the effectiveness of your time. Remember, legislators are people just like us.

Finally, a sixth suggestion relates to the all-important governing bodies that oversee the practices of many of us: state licensure boards. Early in my career, my role in state professional associations led me to attend numerous meetings of our state board of counseling. Not only was this necessary and valuable as it related to the issues under consideration, but it also contributed to my interest in serving on the board and eventually resulted in my appointment to this position in my home state of Virginia. Before my appointment, while attending the meetings and advocating for things that weren’t necessarily in line with the board’s thinking at the time, I received a wonderful compliment when one of the board members said to me, “We don’t always agree with what you have to say, but we appreciate the way you conduct yourself.”

Opportunities to advocate for the profession frequently present themselves, and we need to take advantage of them, whether our audience is the general public or our fellow counselors. Attending a meeting of your state counseling board is an easy step; most boards must meet in open session, and their activities are matters of public record. Public comment is usually received at the beginning of each meeting, not just when controversial items are being debated. These are free, easy opportunities for counselors to speak in a public way about issues of importance to the profession. Serving on such a board is also a very valuable way to engage in advocacy on behalf of the profession.

Clearly, there are numerous ways for counselors to engage in advocacy. Each of us should be able to identify a few ways to get involved, either based on the suggestions in this article or by staying alert to other advocacy opportunities. Whether it involves the somewhat tongue-in-cheek avoidance of the “t” word or the more substantial activity of attending a state counseling board meeting, each counselor is presented with daily opportunities to engage in the activity of advocacy.

To this counselor at least, it seems that we earn the right to express our displeasure only when we actively engage in advocacy. Not doing so contributes to some of the obstacles we currently face in attaining the respect and consideration that the counseling profession both needs and deserves.




Kevin Doyle, a licensed professional counselor and licensed substance abuse treatment practitioner, is an assistant professor and co-coordinator of the counselor education program in the College of Education and Human Services at Longwood University in Virginia. Contact him at doyleks@longwood.edu.

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Saturday keynote: Counselors are the magic pill

By Bethany Bray March 14, 2015

Counselors Jeffrey Kottler and Richard Balkin delivered a fast-paced, information-packed keynote talk peppered with humor, visual clips and abundant insight this morning at the ACA 2015 Conference & Expo in Orlando, Florida.

The duo kicked off the conference’s second day with an address about the importance of

(Left to right) Jeffrey Kottler and Richard Balkin deliver the Saturday keynote at the 2015 ACA Conference & Expo.

(Left to right) Jeffrey Kottler and Richard Balkin deliver the Saturday keynote at the 2015 ACA Conference & Expo.

relationships – both in and outside the counseling office.

Clients look more for a connection, relationship and support than a diagnosis or other trackable data, Balkin said to the standing-room-only crowd.

There is no “magic pill” intervention, theory or technique that counselors can offer clients to automatically make them feel better. Instead, counselors themselves are the magic pill, Balkin said.

Balkin and Kottler have very different background and styles, but their keynote’s engaging back-and-forth made it clear they are both very dedicated and passionate about what they do.

Balkin is a researcher and professor at the University of Louisville and the editor of the Journal of Counseling & Development. Kottler, a prolific author, splits his time between California State University in Fullerton and Nepal, where he founded a nonprofit that supports young women who are at risk of becoming forced into early marriage or sex slavery.

ACA President Robert Smith asked Balkin and Kottler to co-present the Saturday keynote at this year’s conference, a pairing the duo jokingly referred to as a “shotgun marriage.”

“I believe in data, but I believe in the data of stories,” said Kottler, who did a book signing after the keynote. The telling and trading of stories is what creates and retains relationships, said Kottler. It’s also what makes us human. That’s why it is so important that counselors facilitate clients telling their own stories.

Counselors don’t always have to fully understand their clients, Kottler said, but the client must feel they are understood by the counselor.

The duo touched on several points that make a difference in counseling, from keeping clients engaged and being “fully present” as counselors to assessing outcomes and working towards goal with a client. A counselor should make adjustments to the relationship to meet the client’s needs as therapy progresses, said Balkin.

But sometimes, a counselor’s role is simply to hold the client’s sadness, Kottler said. Often, that

includes loving a client in a way they’ve never been loved before – with respect and without manipulation.

“So much of what we do is love people,” said Kottler. “We call it compassion, we call is caring, we call it empathy.”


ACA President-elect Thelma Duffey (at far right) greets the standing-room-only crowd prior to the Saturday keynote.

ACA President-elect Thelma Duffey (at far right) addresses a standing-room-only crowd prior to the Saturday keynote. (Photos by Bethany Bray/Counseling Today)




See images from the 2015 ACA Conference & Expo, including the Saturday keynote, at flickr.com/photos/23682700@N04/




Related reading:

See Counseling Today’s Q+A with Balkin and Kottler: ct.counseling.org/2015/01/its-all-about-the-relationship-qa-with-richard-balkin-and-jeffrey-kottler/




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


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


Maya Angelou remembered as advocate, inspiration to counselors

By Bethany Bray May 28, 2014

Maya Angelou, noted poet, author and inspiration to many counselors, passed away today at age 86.

Angelou, a longtime professor at Wake Forest University, gave the 1997 keynote address at the American Counseling Association’s annual conference in Orlando, Florida.


Maya Angelou, American poet and author. Image via Wikimedia Commons.

“I still remember her ACA conference keynote more than 17 years later,” says ACA Chief Professional Officer David Kaplan, a past president of the association. “Her poetry was enthralling and her passion made you feel as if you were the only one in the room – even though you were surrounded by thousands. It was the most memorable ACA keynote I have ever witnessed and her passing makes me sad that others will not have the opportunity to hear her speak in person.”

An article in the May 1997 issue of Counseling Today describes Angelou’s keynote address at the ACA conference as “brilliant and moving.”

More than 5,000 people attended. She concluded the hourlong speech by reciting her poem “A Brave and Startling Truth,” which was met with a standing ovation. (The poem is included at the bottom of this article.)

“Angelou lifted the spirits of all who were lucky enough to attend,” states the article. “… [She] lauded the exquisite power of counselors, saying ‘you are the best we are, and the best we can hope to be.’”

All people must support each other and teach love, and that is what counselors do, Angelou told the audience.

Angelou grew up in Jim Crow-era Arkansas, which she chronicled in her landmark 1969 book I Know Why the Caged Bird Sings.

Angelou wrote more than 30 books during her lifetime and won three Grammy awards for spoken-word albums. She also directed, wrote and acted in movies, plays and television programs and was a lecturer, dancer, singer and civil rights activist.

Rebecca Daniel-Burke, a counselor and ACA’s director of professional development, said Angelou has been an inspiration to her and she, in turn, has used Angelou’s writings to inspire her counseling clients.

“When I was 25 years old, I lived in Manhattan. I went to the New York Public Library and made a decision to read all of the autobiographies written by women,” Daniel-Burke says. “When I got to I Know Why the Caged Bird Sings, I was in for a treat. Later in life I became a counselor and started giving my clients inspiring poems. One I have given to many women is ‘Still I Rise.’ [Angelou] has provided inspiration to me, my clients and infinite numbers of women.”

Angelou died quietly May 28 at her home in Winston-Salem, North Carolina, said her literary agent, Helen Brann.

In her last tweet on May 23, Angelou said, “Listen to yourself and in that quietude, you might hear the voice of God.”



A remembrance of Maya Angelou, from American Counseling Association CEO Richard Yep

“I have two very distinct memories of Maya Angelou. The first is when I was in high school and was assigned to read I Know Why the Caged Bird Sings. Even at that young age, I was moved and still remember the impact that her biography had on me. She was a woman of such inner strength and fortitude.

The other memory I have was in 1997 when Dr. Angelou accepted ACA’s invitation to be our keynote speaker at the annual conference. The contract from the speaker’s bureau was very clear that we were to meet her plane when it arrived and that staff was to follow her in a separate car to the hotel.

We made sure she got into the limo and headed to the other car when she asked what we were doing. When told that we would be in a different car, she said that was nonsense and that we were to ride with her! On the ride to the hotel, she was engaging, asked about our life and our careers, and made us feel so comfortable. When she went to the stage to present her keynote, she even referred to those of us who met her at the airport by name. Gracious, welcoming and a very unique woman.”




Counselors, how have Maya Angelou’s life and writings inspired you?

Scroll down to post your thoughts and memories of her legacy and impact on the counseling profession.




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

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



A Brave and Startling Truth

By Maya Angelou (recited by the author at the American Counseling Association’s 1997 annual conference)

We, this people, on a small and lonely planet
Traveling through casual space
Past aloof stars, across the way of indifferent suns
To a destination where all signs tell us
It is possible and imperative that we learn
A brave and startling truth

And when we come to it
To the day of peacemaking
When we release our fingers
From fists of hostility
And allow the pure air to cool our palms

When we come to it
When the curtain falls on the minstrel show of hate
And faces sooted with scorn are scrubbed clean
When battlefields and coliseum
No longer rake our unique and particular sons and daughters
Up with the bruised and bloody grass
To lie in identical plots in foreign soil

When the rapacious storming of the churches
The screaming racket in the temples have ceased
When the pennants are waving gaily
When the banners of the world tremble
Stoutly in the good, clean breeze

When we come to it
When we let the rifles fall from our shoulders
And children dress their dolls in flags of truce
When land mines of death have been removed
And the aged can walk into evenings of peace
When religious ritual is not perfumed
By the incense of burning flesh
And childhood dreams are not kicked awake
By nightmares of abuse

When we come to it
Then we will confess that not the Pyramids
With their stones set in mysterious perfection
Nor the Gardens of Babylon
Hanging as eternal beauty
In our collective memory
Not the Grand Canyon
Kindled into delicious color
By Western sunsets

Nor the Danube, flowing its blue soul into Europe
Not the sacred peak of Mount Fuji
Stretching to the Rising Sun
Neither Father Amazon nor Mother Mississippi who, without favor,
Nurture all creatures in the depths and on the shores
These are not the only wonders of the world

When we come to it
We, this people, on this minuscule and kithless globe
Who reach daily for the bomb, the blade and the dagger
Yet who petition in the dark for tokens of peace
We, this people on this mote of matter
In whose mouths abide cankerous words
Which challenge our very existence
Yet out of those same mouths
Come songs of such exquisite sweetness
That the heart falters in its labor
And the body is quieted into awe

We, this people, on this small and drifting planet
Whose hands can strike with such abandon
That in a twinkling, life is sapped from the living
Yet those same hands can touch with such healing, irresistible tenderness
That the haughty neck is happy to bow
And the proud back is glad to bend
Out of such chaos, of such contradiction
We learn that we are neither devils nor divines

When we come to it
We, this people, on this wayward, floating body
Created on this earth, of this earth
Have the power to fashion for this earth
A climate where every man and every woman
Can live freely without sanctimonious piety
Without crippling fear

When we come to it
We must confess that we are the possible
We are the miraculous, the true wonder of this world
That is when, and only when
We come to it.



Understanding bulimic dissociation to create new pathways for change

Rebecca Heselmeyer & Eric W. Cowan December 1, 2012

Given the extensive research on eating disorders, motivated clients and a gold standard treatment — cognitive behavior therapy — it is perplexing that recidivism rates remain so high for bulimia. It behooves us as counselors to investigate possible hindrances to effective treatment and adjust our approach accordingly for those clients with bulimia who have not achieved long-term resolution. It is notable that, despite the substantial evidence linking dissociation and bulimia, many counselors remain unaware of this connection. Further, the nature of the relationship has not been sufficiently explored. In this article, we apply principles from self-psychology to bulimic dissociation and use this new understanding to inform clinical practice.

When I (Rebecca) first met Sonya, she sat across from me tearfully expressing the shame she felt about her binging and purging and the feeling of defeat she experienced from failed efforts: to stop thinking about food, to stop scrutinizing her body, to stop mindlessly gorging on food and then rushing to vomit. Sonya presented as many clients with bulimia do — she expressed a desire to change and a willingness to try whatever therapeutic assignments I may assign to her. Rather than engage with her in familiar and expected territory by focusing on food (nutrition, food journals and so on), I turned my attention to a different part of Sonya’s experience, inviting into our conversation the part of her identity that up until then had likely been unacknowledged and invalidated repeatedly. We have labeled this the dissociated bulimia identity (DBI). To explain our reasoning for yet another coined term with a nifty initialism, let’s shift gears and look at the underlining theory.

Self-psychology and the vertical split

Heinz Kohut proposed that children need specific interactions and feedback from caregivers to formulate cohesive, integrated selves. An important part of this process involves mirroring, in which caregivers demonstrate accurate, empathic affective attunement with the child. For example, a child may cry out upon seeing shadows in a dark bedroom at night. An attuned care provider might respond by giving language to what the child is experiencing (“You are afraid”) and comforting the child. Through such interactions, the child not only learns language for his or her affective state, but also learns that he or she can be afraid and still be loved. Gradually, with additional interactions in which the caregiver reflects the child’s fear in a nurturing manner, this affective state becomes identified and integrated into the child’s sense of self.

Assuming the care provider responds to the multitude of emotional experiences with validating, reflective attunement, the self then develops into a cohesive being where all affective states — love, joy, fear, grief, discouragement, excitement, loneliness and so on — have an identified and accepted place. The child has been welcomed into the world of shared meanings and connections and has formed a cohesive sense of self composed of, to use Harry Stack Sullivan’s language, “reflected appraisals.” Further, the process that enables identification and integration also teaches the child about self-care; the nurturing and soothing interactions with the caregiver over time become internalized so that the child develops the ability to self-soothe and manage emotional experiences without relying on the caregiver’s presence.

Now imagine the same child in the frightening, dark bedroom, crying out at the lurking shadows. In this house, the caregiver responds with taunts, calling the child a scaredy-cat and snapping at her to go back to sleep “or else.” Continued interactions of this nature also identify the affective state while invalidating the experience of it. The child is taught that fear is not allowed and is shamed for experiencing it. There is no comforting hug or lullaby to internalize; there is only the message of rejection. There is a disconnect between the child and others, which results in a parallel disconnect from internal thoughts and feelings. Dependence on the caregiver is crucial for survival, so anything that might threaten this relationship is sacrificed. Consequently, affective states met with invalidation become disavowed and denied integration into the “socially acceptable self.” But where do these affective states go?

Kohut proposed that lack of adequate and empathic mirroring results in a “vertical split” — a metaphor for the partition between self-experiences integrated into the “normal” self and disavowed affects and frustrated developmental needs. Repression can be understood as a horizontal split, with unconscious desires tucked away deep in the psyche and blocked from the rest of the aware mind and body. The vertical split, on the other hand, designates a chasm between selves: the integrated affects and being states that were met with empathic mirroring and those that were sacrificed in an attempt to maintain the essential relationship with primary caregivers.

Therefore, for clients with bulimia, validated affective states become integrated into the normal, socially acceptable self, while invalidated affective states are sequestered on the other side of the split, forming the unacknowledged, rogue DBI. Acknowledging this part of the self-experience has been deemed threatening and forbidden. Perhaps more important, the child never learns to effectively acknowledge, self-soothe and manage this part of self-experience. Needless to say, mere ignoring cannot relieve the emotional demands of loneliness, lust, anger, guilt, despair and other feelings. When the DBI demands attention, the now-adult client may address it in the one way she or he knows how — with food.

Media teach us time and again that food is a source of comfort, pleasure and love. The absurdity of media campaigns goes so far as to sexualize food. Jean Kilbourne, in her “Killing Us Softly” lectures, observes the potency of a variety of media messages, including ones that offer food as a substitute for relationships. Food is also culturally anchored in our experiences: family gatherings, celebrations and times of mourning. Our bodies respond physically and physiologically to eating. In the most basic sense, food literally fills a void within us. Binging provides momentary relief and escape, and the process at work is twofold.

Dissociative symptoms are present throughout the binge-purge cycle, with peaks occurring during the binge and immediately after the binge. Dissociation is commonly thought of as an escape from painful psychological experiences. Dissociative symptoms are on a continuum ranging from minor alterations in perceptual functioning to significant disruptions, such as a dissociative fugue. The dissociation associated with bulimia is primarily categorized as mild to moderate. Clients may feel out of control or have a detached experience of watching themselves binge.

Let’s explore the dual process at play, using Sonya as an example.

Dissociation, revisited

Sonya would often report the quick onset of the urge to binge. As she began, her feelings of disconnectedness and lack of control grew, enabling her to eat beyond capacity by blunting both the physical and emotional discomfort she would otherwise experience. Psychologically, the dissociative symptoms she experienced also provided temporary relief from the triggering affective state. At the same time, the dissociative experience allowed Sonya to “jump” the vertical split and access the very region housing the unmet need that was triggering the binge — in her case, a deep sense of helplessness. This dis-integrated part of her self-experience that was reproached during her development has shown up in her adult life, but she lacks the ability to effectively identify, manage and attend to it.

The binge-purge behavior brings with it dissociative processes that temporarily provide Sonya with both an escape from pain and access to the region where she can acknowledge and soothe that otherwise denied self-aspect. The function of dissociation is to “escape” to a very specific and important place: her DBI. In other words, while Sonya is desperately (and ineffectively) seeking physical comforts, her psychological self is likewise seeking to self-soothe the neglected and needy DBI. She is momentarily allowed access to this outlawed part of the self and can attend to the very real need for nurturing and validation.

With the conclusion of the binge also comes the conclusion of dissociative symptoms. Sonya becomes more aware of her physical self — and simultaneously is returning to her socially acceptable, normal psychological self — and is swept by feelings of shame and guilt. Physically she feels great discomfort and embarrassment at the quantity of food she has consumed, while psychologically she has trespassed to visit and comfort the forbidden DBI. She has broken the rules — physically by food consumption and psychologically by traversing the vertical split. Guilt reigns supreme, and she purges to expunge herself of the harm done.

Through this lens, the functionality of the binge-purge behavior and dissociation can be seen as the client’s best effort to attend to a disorganized self-experience. For many clients, including Sonya, bulimia is a clinical presentation that, at its core, is a disorder of self rather than being fundamentally rooted in body image concerns. The clients’ repeated attempts at self-care through the use of food fail because the core unmet developmental needs are never brought out of exile and given their rightful place in the integrated “normal” self. Symptom-focused counseling that serves largely as behavior management — food journals, nutritionists, love-my-body activities — prove ineffective for these clients because there is no room for the underlying disorder of self to emerge in the therapeutic dialogue. For this to happen, there needs to be a shift in the counseling mindset and conversation.

Clinical applications

If I had partnered solely with Sonya’s desire to extinguish her bulimic behaviors, I would also have partnered solely with her “socially acceptable” self  — that part of her that genuinely does want to stop binging and purging. Concurrently, I would have communicated to her that her DBI was not welcome.

The DBI relies on the function of her behaviors for much-needed psychological care, so there is likely a very substantial part of Sonya that wants to binge and purge and has no intention of giving this up. Focusing the counseling conversation on ways to extinguish and change behavior, without also addressing the purpose of the behavior and offering an alternate way of accomplishing the function, invalidates the part of the client’s experience that appreciates and needs the behavior. If approached in this manner, the client’s DBI is likely to “go into hiding” for fear that successful counseling will result in its extinction (rather than integration). In effect, this guarantees an unsuccessful long-term counseling outcome.

Instead, I invited Sonya to tell me about the part of her that wants to binge and purge. This is a potentially shame-laden and socially ostracized part of Sonya’s being, so it is important for me to seek it out and welcome it rather than assume it will enter the therapeutic dialogue without active and sometimes repeated invitation. Counselors need to provide an experience in which all parts of the client’s experience — both the desire to cease behavior and the desire to maintain it — are welcomed and validated. We encourage counselors to address the DBI directly (“Tell me about the part of you that needs to keep doing this”) or by using third-person language (“Tell me about her — the part of you that defies your attempts to control her”). In addition, use language that demonstrates an appreciation for the adaptive function of bulimia that is, in a sense, trying to help.

Occasionally, it may serve as a powerful paradoxical intervention for the counselor to urge the client not to give up the binge-purge behavior too quickly. Clearly, this intervention is not appropriate when working with clients who have significant health risks. But for clients in relative physical good health, and especially for those who have had extensive counseling, an intervention of this sort likely will be unexpected and get beyond psychological resistance by “siding” with the DBI against the socially conforming self. You can observe to clients how cruel they are to their bulimic selves when they use disparaging language (“I’m such a fatso loser when I binge”).

Once it is established in the therapeutic dialogue that all parts of the client’s experience are welcomed and validated, new pathways for healing can emerge because the client, with the counselor’s support, can begin to acknowledge and express the frustrated developmental needs that are the driving force behind the bulimic behavior. An important part of this approach is keeping the therapeutic conversation focused on the client’s inner world of needs, feelings and thoughts, particularly those that are outside the client’s normal experience, so the client can expand self-reflective awareness.

Once clients gain insight into the role their bulimia has served in managing emotions and needs, a powerful experiential process unfolds as the counselor provides the empathic mirroring response that was previously withheld during the client’s childhood development. Counseling provides the repeated, accurate, empathic attunement that the client’s caregivers failed to supply. Just as over time the child internalizes the caregiver’s ability to soothe and comfort, the client’s new awareness of emotional triggers, coupled with the empathic, attuned response from the counselor, allows the client an opportunity to begin addressing and meeting her or his needs in a new, direct way. The ongoing process of welcoming the formerly forbidden self-experiences into the counseling relationship gradually breaks through the wall of the vertical split, allowing a merging of selves into a now fully integrated self. As this happens, the need for bulimic behaviors diminishes and, without a purpose, the behaviors eventually cease.

Similar to the experiences of other clients, the turning point for Sonya came when she felt at liberty to speak about the part of her that could not imagine life without binging and purging. Gradually, Sonya’s sense of inner connectedness and connection with others grew, and she became skillful at recognizing her emotional needs and attending to them in healthy ways. Her binging and purging has subsequently tapered.

We hope you will find this conceptualization and the suggested techniques enriching to your counseling practice.

“Knowledge Share” articles are based on sessions presented at American Counseling Association Conferences.

Rebecca Heselmeyer is a staff counselor in residence at the James Madison University (JMU) Counseling and Student Development Center, adjunct instructor for the JMU Counseling Programs and a member of the Rockingham Memorial Hospital Psychiatric Emergency Team. Contact her at heselmrj@jmu.edu.

Eric W. Cowan is a professor in the Department of Counseling and Graduate Psychology at JMU and the author of Ariadne’s Thread: Case Studies in the Therapeutic Relationship. Contact him at cowanwe@jmu.edu.