Tag Archives: narrative therapy

Stories of empowerment

By Lindsey Phillips September 26, 2017

In 2009, writer Chimamanda Adichie gave a TED Talk on the danger of reducing people to a single narrative, using her own personal stories to illustrate the complexity of individuals. In one of those stories, she revealed how her college roommate in the United States had a single understanding of Africa — one of catastrophe. Adichie, a middle-class Nigerian woman, did not fit this single-story narrative. To her roommate’s surprise, Adichie spoke English, listened to Mariah Carey and knew how to use a stove.

Adichie points out that people are impressionable and vulnerable in the face of a story. Stories are powerful, she says, but that power is dependent on who is telling the story and how it is told. “Power is the ability not just to tell the story of another person, but to make it the definitive story of that person,” Adichie says.

Storytelling can also be used to empower people, which is one of the primary functions of narrative therapy. In many ways, the story of narrative therapy began in the late 1970s through shared stories and conversations between Michael White and David Epston. This counseling approach assumes that culture, language, relationships and society contribute to the way that individuals understand their identities and problems and make meaning in their lives.

The narrative approach also separates the person from the problem — a technique that allows clients to externalize their feelings. “The spirit of externalizing the problem is so that the client doesn’t see that as something that they can’t change,” says Kevin Stoltz, an American Counseling Association member who is an assistant professor of counselor education at the University of New Mexico. Moreover, this approach places clients as the experts in their own lives (see sidebar, below).

Don Redmond, an associate professor of counseling at Mercer University in Atlanta and director of the university’s Center for the Study of Narrative (CSN), points out that White and Epston’s original vision of narrative therapy was not prescriptive. “It really is in some ways theoretical, even though there are specific techniques that you can learn. It really is about celebrating and appreciating each person’s unique story and helping them frame it in a way that is more self-affirming and less self-defeating,” he explains.

(Re)writing memories

Narrative therapy can help clients release the burden of painful memories. Cheryl Sawyer, professor of counseling at the University of Houston–Clear Lake, started using narrative therapy in part because of an aha moment she experienced while watching a scene in the movie Harry Potter and the Goblet of Fire. In the scene, Hogwarts headmaster Albus Dumbledore shows Harry the Pensieve, an object that stores thoughts and memories.

Sawyer specializes in trauma counseling and often works with children who are refugees or who have been abused. She wanted to help her child clients release their traumatic memories, so she created a narrative project in which children create memory books. As Sawyer explains, the memory books operate like the Pensieve, allowing the children to unpack their trauma and give it a safe place to live.

Children do not narrate the episodes of their lives chronologically, Sawyer notes. Instead, their level of trust determines where their stories begin. If they trust the counselor, she says, they will reveal more intimate details (e.g., “I was beaten up at my birthday party”) rather than offering only the generic version (e.g., “I received presents”).

Because children’s narratives typically are structured but not sequential, it can be hard to discern cause and effect, says Sawyer, a member of ACA. To overcome this, counselors can have child clients place events from their stories on a timeline. This technique allows clients to see the cause and effect, understand their own behavior and possibly project what might come next based on the patterns they notice.

In Stoltz’s experience, Adlerian theory and early recollections (an Adlerian process in which counselors instruct clients to remember actual events from their early life) work well with narrative therapy. This is because they help people understand their self-concept and self-identity and make meaning out of the experiences embedded in their lives.

In a classical Adlerian sense, early recollections are defined as memories before age 10, Stoltz says. “The time frame … is somewhat artificial in some aspects, but in other aspects, it’s good to understand the very core of when those first experiences started to come out for people — what they remember, what they really think is poignant that … shapes their beliefs and their worldview,” he says. Childhood memories are often distorted by one-dimensional thinking because people’s perception in childhood is different than in adulthood, he adds. Re-storying involves recalling these early memories and reinterpreting them with an adult mindset that is capable of higher cognitive exploration.

Stoltz is currently applying guided imagery to career narrative stories. As he explains, clients often have a fictional or real-life person they admired when they were young because the person’s traits or behaviors matched the way they thought the world should operate. Often, they used this hero narrative to move through life, Stoltz says.

For example, with one client who presented a heroic memory of Spider-Man, Stoltz noticed a pattern: The client kept using the word conflict in his narrative. In discussing this pattern, they discovered that the client no longer wanted to let his responsibilities be an excuse for shying away from conflict. So, they worked together to determine how the client handled conflict currently, how the client wanted to handle it in the future and how the client’s role models handled conflict.

“Guided imagery is a way of projecting that hero data onto a future career decision or a career transition. And it makes it more lifelike in the session for the person. It begins to allow them to purposefully imagine and really begin to apply that self-concept to the next step in their career,” Stoltz says.

Stoltz uses narrative data from the career construction interview to develop individualized scripts, including ones focused on supporting client identity, meaningfulness of work and aspects of adaptability and skills. “The narrative approach is always about writing the next chapter, and this is a way of applying the next chapter to an imagined world, a daydream,” he explains.

Pictures worth a thousand words

Words can sometimes fail clients. If clients cannot or will not articulate their stories with words, counselors must be creative and find another way for clients to express themselves, Redmond says. “The more versatile a counselor can be, the better,” he adds.

Sawyer works with some clients who possess limited vocabularies because they have lived on the streets from an early age and haven’t been exposed to higher levels of language. For example, a child might say, “I’m really mad,” but that statement is insignificant compared with what he or she is actually feeling.

When children don’t have all the words they need to express their thoughts, Sawyer relies on pictures. She asks clients to draw pictures, find pictures on the Internet or even go out and take pictures that support the deeper level of emotion in their personal stories. Often, she will take a series of pictures into the counseling session and ask clients if any of the pictures express how they feel that day and why that image best exemplifies what they are feeling.

Technology is providing yet another avenue for clients to communicate their stories. Sawyer finds that children and adolescents are often more comfortable texting than talking, so she has started using technology as a tool in storytelling. She creates digital narratives by typing the clients’ stories into PowerPoint slides. Then, she gives clients the option of adding music, images or art to depict how they feel. For example, one client added a picture of his father’s death certificate, and another client added a picture of a pair of shoes she was going to send her sister before her sister was murdered.

Redmond also combines technology and narrative therapy. At Mercer University’s CSN, counseling students interview people in the community and then convert these interviews into digital narratives (approximately five-minute videos) by selecting pictures, art and music to complement each person’s narration of his or her own story. One woman whom Redmond interviewed painted and sang to express her story, and both aspects were incorporated into her digital narrative. Pairing descriptions of her artwork with actual images of it captured her essence more fully than if she had been only interviewed, he adds.

These digital narratives allow individuals not only to rewatch their stories but also to share their stories with others. In fact, one of Redmond’s goals for CSN is to create a digital library that will help individuals going through a difficult time to realize that they aren’t alone.

Taking a back seat

Narrative therapy falls under postmodern theory. “One of the hallmarks of the postmodern approach is embracing the fact that there is subjectivity with an individual’s perception and what they’ve been through and not having the counselor come in and be the expert,” Redmond says. With narrative therapy, he explains, clients are the ones verbalizing the new or modified narrative of their lives, and counselors only paraphrase or mirror what clients are saying.

Because narrative therapy is client driven, it is more important for clients to understand how they are feeling than for the counselor to understand it, Sawyer says. “[Counselors are] the tool that [clients are] using, the base that they’re using, to tell their stories for themselves,” she explains. Clients must be provided with a safe space where they can share their stories and learn to express their feelings about what happened.

As a volunteer with Bikers Against Child Abuse, Sawyer often attends court cases involving children who have been abused, and she has observed children’s frustration when lawyers interrupt or guide their stories in answer to a specific question. For Sawyer, this observation further underscores the importance of allowing clients, not counselors, to direct and narrate their stories. As she points out, counselors are facilitators for the client’s story, so their job is to listen and help the client structure the order of the story, not the content.

Stoltz has found that the process of deconstructing and reconstructing the elements of a client’s story is often challenging, particularly for counseling students. To demystify this process, in 2015, Stoltz, along with Susan Barclay, published a guidebook, The Life Design ThemeMapping Guide, that provides counselors with a process for deconstructing narrative data, developing specific themes for the career construction interview and helping clients reauthor their stories. For the past five years, Stoltz has used this technique to train students to deconstruct and theme elements together.

Taking a back seat and allowing clients to guide the session can be particularly difficult for new counselors because they want to feel that they are accomplishing something, Stoltz says. They want to sense that the client has made a decision and is moving in a direction. Drawing on James Prochaska and Carlo DiClemente’s Stages of Change model, Stoltz reminds counselors that they’re “raising awareness now. You’re in the beginning of the change model. You’re in the contemplation stage or precontemplation stage. You’re not looking for movement. You’re looking for insight or awareness, the aha moment.”

A voice for marginalized, multicultural populations

With narrative therapy, clients inform counselors about their world, values and beliefs. In fact, early recollections provide counselors with an inside view of the client’s culture, Stoltz says.

Within this dynamic, a counselor’s culture and values may differ from the client’s, but counselors should not place cultural judgment on what clients have done, Sawyer says. For example, clients might disclose that they have offered sex in exchange for food, or they may use profanity in telling their story, but counselors must refrain from passing judgment, even if they think this act or language is hideous or immoral based on their own cultural perspective. Clients must feel safe to use their own language and words to freely tell their stories, Sawyer adds.

Redmond agrees that narrative therapy is compatible with cross-cultural environments because narrative counselors do not presume to know and tell clients about their problems. He also realizes that too often, the stories of marginalized individuals remain unheard. One of Redmond’s inspirations for creating CSN was StoryCorps, an oral history project that allows people to record their stories in a studio by having a family member or friend interview them. The recordings are then archived at the Library of Congress. Through CSN, Redmond expanded the project to include marginalized populations (e.g., people who are homeless, refugees) who do not readily have someone available to interview them and record their stories.

Redmond believes the community plays a significant role in narrative therapy. Therefore, CSN’s purpose is both to allow counselors to practice their listening skills and to provide a service to the community by letting people who are marginalized know that they are valued. Even though the CSN interviews are not considered official therapy, most people would agree that the simple act of telling one’s story can be therapeutic, Redmond says.

Redmond’s personal story also played a role in the creation of CSN. Besides the fact that he has always enjoyed stories, Redmond had two professional experiences that strengthened his belief in the power of narrative therapy. First, in his role as a supervisor at Hillside in Atlanta, a facility that serves children with severe emotional behavior disorders, he discovered that the children with the most severe behaviors and who had been at the facility the longest also possessed the most strengths. This observation made an impression on him, especially considering all the negative messages directed at these children, many of whom had been abused and were in and out of foster care.

The second experience occurred when Redmond was an access clinician at a community services board. Many individuals were at this facility under court order or because they were dealing with mental health issues. While conducting intake interviews, Redmond amused himself by writing down the clients’ strengths (e.g., intelligent, strong work history, sense of humor, family support). At the end of the interview, he would tell the clients the strengths he had jotted down and then would ask if they wanted to add anything. He often witnessed powerful reactions from the clients, including those who cried and said no one had ever told them that they had strengths.

These two experiences reinforced Redmond’s belief that “people start creating negative self-stories, and they start to only believe the negative images, and then they forget about the strengths that they have.” Therefore, Redmond advises counselors never to forget to account for the strengths of their clients, no matter the difficulty of the case.

The cultural awareness gleaned from narrative therapy also applies to clients, allowing them to question their own cultures. Often, Stoltz says, the difficult part is relating the memories and stories back to the client’s present life. Some clients grasp this concept more easily than others, and some struggle to understand how childhood events are still affecting them as adults. The latter scenario is challenging. “Early memories really are a good tool to have to be able to talk to people from different cultures because [there are] stories in every culture. … Memories are a story, and [they are] a way of relating that whole story back to the person,” he says.

Validating narrative therapy

Critics of narrative therapy often question how counselors objectively measure narrative techniques, which are subjective. “I think we’re in the infancy of starting to measure these kinds of things. I think we’re just beginning to rediscover some of the things that have been helpful in mental health counseling, and we’re applying those as new techniques to the career narrative area,” says Stoltz, who served as chair of the research committee for the National Career Development Association, a division of ACA. At conferences, counselors are discussing how the narrative approach works, and they are doing outcome research that says it works, but they are not yet validating the process, he adds.

“You cannot quantify emotion,” Sawyer acknowledges. She and her colleagues attempted to measure narrative approaches by administering a pretest and posttest to children who had suffered trauma. They found a valid instrument and administered it in the children’s native language, but the formality of the instrument and the fact that the counselors had not yet established a relationship with the clients caused some clients to leave prematurely. Based on this experience, Sawyer decided not to administer the posttest and concluded that sometimes narrative therapy is not about research; it is about clients and their needs.

The best method Sawyer has found for measuring the success of narrative therapy involves having clients point to shapes (e.g., small, medium and large circles) to indicate how big their problems are both before and after counseling sessions. Using this method, she has found that narrative therapy has a positive effect because for most children, the representative shape decreases in size at the end of the counseling sessions. However, because counselors cannot account for all variables — if court is over, if the client is living in a home with 14 other children, if the client has learned to speak English and so on — it is impossible to know whether clients have improved strictly because of narrative therapy, she points out.

Redmond is a proponent of mixed-methods research because quantitative research (e.g., a Likert-type scale) provides more breadth than depth, whereas qualitative research provides the depth. In addition, they complement each other: Quantitative research can provide counselors with great ideas for qualitative research and vice versa. Redmond recommends first using quantitative research, such as a survey, because clients find it less threatening and less personal, but it will still get clients thinking about their experiences. Then, counselors can ask clients the magic question: “Is there anything you haven’t discussed that you would like to talk about?”

Stoltz has discovered that finding thematic codes for categorizing narrative data is one way to measure narrative techniques. For example, people who engage in storytelling about traumatic events in their lives tend to integrate these life events into meaningful stories and report higher life and career satisfaction.

“Preliminary evidence is beginning to show that when trained people read these stories, they come to the same conclusions,” Stoltz says. “That’s an important first step in validating …
this process.”

In addition, digital narratives may provide opportunities to quantify narrative interventions in the future, Redmond says.

Integrating narrative practices

Narrative therapy is not for the lightweight, and it is not as easy as it sounds, Sawyer says. In fact, self-doubt can prevent counselors from using narrative techniques, she points out. To avoid this, counselors need practical experience. Just taking one course or workshop or reading a book on the topic won’t mean that counselors will know how to use the approach correctly. Instead, Sawyer argues that counselor training should involve a holistic approach in which counselors expose themselves to the topic not only through courses, books and articles but also by practicing under supervision and processing all along the way.

Also, some counselors are hesitant to incorporate mental health-based approaches if their training is in another specialty such as career counseling. Stoltz, however, stresses the importance of taking an integrated perspective because people have multidimensional experiences that are not mutually exclusive. “Career counseling is often seen as limited to the career dimension, but it is really counseling with a career goal in mind,” he says.

For Stoltz, it makes sense to apply narrative therapy to career counseling because there is always a story behind one’s career. Furthermore, many people spend eight to 10 hours working every day, and work stress is a significant contributor to a person’s well-being or absence of well-being, he says. Despite this, counselors are generally not incorporating work aspects into mental health, he points out.

Thus, Stoltz argues that counselors “need to rethink [their] specialization construct.” Unfortunately, it is easy for counselor educators to design courses that address a certain standard (e.g., a career counseling course, a trauma course, a multicultural course). However, when counselor educators create stand-alone courses, students often move from one course to another without integrating those courses, Stoltz says. To avoid this, he incorporates basic counseling skills alongside career counseling because students must learn to respond to content and meaning before they can help a client deconstruct a story.

Sawyer’s counseling program at Houston–Clear Lake integrates narrative therapy into the curriculum by introducing narrative therapy as a counseling tool and working narrative techniques into multiple courses. “It is not the only way to counsel but … like how everybody knows how to do Rogers, everybody knows how to do Gestalt … all of my students know how to do CBT [cognitive behavior therapy] and trauma-focused CBT, and they all know how to do narrative counseling,” she says.

Stoltz agrees with expanding counseling areas, but he also worries that as counseling training becomes broader, counseling programs are finding it difficult to retain depth. Counseling students need to understand both the academic jargon and the practical training associated with those terms, he stresses. “Re-storying needs to be accompanied with a practical, pragmatic application of what that looks like and what that process is,” he says.

Stoltz is helping to bridge this gap by incorporating experience work in his classroom, which is a technique modeled after Mark Savickas’ pedagogical practice. For example, a counseling student might do a case study and follow someone through a career intervention, or a career story, and present this constructed story to the class.

Redmond finds that counseling students infrequently have many opportunities to train specifically in narrative therapy or narrative studies. Currently, students in his program are introduced to narrative therapy under the umbrella of postmodern approaches in a counseling theories course, but his goal is to have students do more specialized work in narrative therapy in the future. As a step toward achieving this goal, he will be working this fall on a proposal for a narrative certificate program.

Authoring the next chapter

Stoltz acknowledges that misinterpretation or a unitary interpretation of a client’s story is one of the pitfalls of narrative therapy. “[Counselors] feel like [we’ve] got the inside track on this because [we] have this psychological knowledge, this counseling knowledge, and [we] have to be careful with that,” he warns.

Often, counselors will make up their mind about what the story means to the client. But the counselor’s job is to test, not to interpret, Stoltz says. Counselors should make the client aware of what they see and test that theme or theory with the client while still respecting that it is the client’s story, he explains. The client is the one who has to live the life and rewrite the story; the counselor’s job is to help the client accomplish this.

Adichie reminds us that “stories can break the dignity of a people, but stories can also repair that broken dignity.” Narrative therapy provides clients with a safe space to tell their stories. With a counselor’s guidance, clients can slowly reject the negative stories and stereotypes that create an incomplete or inaccurate representation of who they are as individuals and replace them with stories that empower them to take control of their lives and regain their humanity.

Stories are powerful, but the person holding the pen is the one who controls the story. Revision is key when writing a novel, and this holds true in narrative therapy as well. People first have to understand and narrate their stories in order to rewrite them and become the authors of their next chapter.

 

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Narrative approaches

As explained in the fifth edition of Counseling and Psychotherapy: Theories and Interventions, edited by David Capuzzi and Douglas R. Gross and published by the American Counseling Association, narrative therapy is based on the following beliefs:

1) Clients are not defined by problems they present in counseling.

2) Clients are experts on their lives, so in counseling, judiciously seek their expertise.

3) Clients have many skills, competencies and internal resources on which to draw when impacting change and growth.

4) Therapeutic change occurs when clients accept their role as authors of their lives and begin to create a life narrative that is congruent with their hopes, dreams and aspirations.

 

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Lindsey Phillips is a freelance writer and UX content strategist living in Northern Virginia.
She has 10 years of experience writing on topics such as health, social justice and technology. Contact her at lindseynphillips@gmail.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

 

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

Investigating identity

By Laurie Meyers November 21, 2016

“W hat are you?”

That is a question commonly asked of individuals who are multiracial. As a society, we have gotten used to checking off a metaphorical — and often literal — “box” when it comes to questions of race. We seem to expect everyone to “just pick one.”

But the population of the United States is becoming increasingly diverse, not just in terms of our nation’s racial makeup, but also in the growing number of people who identify themselves as belonging to two, three or more racial groups.

The U.S. Census Bureau first started letting respondents choose more than one racial category to describe themselves in its 2000 survey. Since then, the multiracial population (defined as individuals who have at least two different races in their backgrounds) has grown rapidly. Between 2000 and 2010, the number of white and black Americans who identified as biracial more than doubled, and the population of Americans who identified as being of both Asian and Caucasian descent grew by 87 percent. In addition, according to information compiled from the family2010 census and the Census Bureau’s 2013 American Community Survey, the percentage of infants born to parents of two or more different races increased from 1 percent in 1970 to 10 percent in 2013. And, of course, in 2008, in a historic event that in part reflects the nation’s growing multiracial population, Americans elected a biracial president, Barack Obama, the son of a black Kenyan farther and a white mother.

The Census Bureau estimates that 2.1 percent of the U.S. population is multiracial. However, in 2015, the Pew Research Center conducted a survey and issued a report, “Multiracial in America,” estimating that 6.9 percent of the U.S. population is multiracial. The Pew study arrived at this figure by taking into account not only how individuals describe their own racial backgrounds, but also the backgrounds of their parents and grandparents, which the U.S census does not do.

The Pew survey also found that many people with mixed racial backgrounds do not identify themselves as “multiracial.” In fact, 61 percent of such respondents identify themselves as belonging to only one race. However, the survey also discovered that individuals’ racial self-identification can change over the years. Some choose to identify with a different part of their racial background later in life or decide to begin identifying as multiracial rather than monoracial (and vice versa).

Counselors who study multiracial issues and in some cases are multiracial themselves say that this finding of shifting racial identity is indicative of one of the core issues of being from multiple races — identity and belonging.

On the outside looking in

“When I was young, I didn’t know I was different,” says licensed professional clinical counselor Leah Brew, who is half white and half Japanese. “Then we moved, and I was made fun of [at her new school] because they said I was Chinese.”

Brew didn’t know what being Chinese meant, but based on the teasing she was subjected to, she assumed it was something horrible. “So I asked my mom if I was Chinese, and she said, ‘No, you’re Japanese,’” Brew recounts. She was relieved but soon found that when she corrected her tormentors, it made no difference. Although Brew was also white, it was her Japanese appearance that mattered to her classmates.

As she grew older, Brew, a professor and chair of the Department of Counseling at California State University, Fullerton, became interested in exploring the Japanese side of her heritage and even traveled to Japan. Although she loved experiencing the culture and the people, she didn’t feel quite at home there either. For one thing, she says, she inherited her white father’s height and towered over everyone on the street. “I thought, ‘No, that’s not it’” — where she “belonged,” Brew says.

“When I moved to California, I thought this was it” because the state has many residents from various racial backgrounds, Brew says. “But the other biracial people I encountered were very dissimilar to me and got their identities from other things, like religion.”

Today, Brew, a member of the American Counseling Association, sees a significant number of multiracial and multicultural clients in her practice. She also helped write the Competencies for Counseling the Multiracial Population, a set of professional counseling practices developed by ACA’s Multiracial/Multiethnic Counseling Concerns Interest Network to competently and effectively attend to the diverse needs of the multiple heritage population. When it comes to her own identity and culture, Brew says she at times sees herself as mostly white and at other times mostly Japanese. She acknowledges that she is always moving back and forth between the two.

C. Peeper MacDonald, a practitioner and counselor educator whose research focuses on multiracial issues, is both white and Native American. Most people assume she’s white, however, which makes MacDonald feel that they are missing or ignoring a large part of who she is.

“I often use the opportunity [the assumption of her monoracial whiteness] to correct people and educate them about my identity,” MacDonald says. “I do, however, often get the sense that people feel that I am reaching. For example, I often hear, ‘Oh, well, everyone in the United States has Native American in them.’”

MacDonald, who teaches undergraduate psychology classes part time at Georgia Gwinnett College and is also counseling and supervising part time at the Atlanta campus of the Savannah College of Art and Design, often feels compelled to “prove” her ethnicity, she says. For instance, she will share her Cherokee name with people, which seems to satisfy them.

It was actually MacDonald’s interest in her family’s Native American heritage that led to her maternal grandfather reclaiming his history. For most of his life, MacDonald explains, her grandfather experienced severe racism because he was a Native American, so he often identified himself as Hispanic instead. MacDonald’s mother was raised by her white mother and a white stepfather and, as a result, has never really considered herself Native American, even though MacDonald says her mother does not look white. It wasn’t until MacDonald started asking as a child about the Native American side of the family that her grandfather, then in his 70s, started to embrace his heritage again.

ACA member Derrick Paladino, who is part Puerto Rican and part Italian American, grew up in a predominantly white neighborhood in Connecticut. When kids at school would question him about “what” he was, Paladino would simply say Italian because that seemed easier and perhaps safer.

Paladino, who also helped to develop the Competencies for Counseling the Multiracial Population, says he didn’t have a lot of contact with the Puerto Rican side of his extended family when he grew up, so he didn’t have much opportunity to explore the Latino part of his identity. When he ultimately decided to go to college at the University of Florida, Paladino says he was thrilled at the prospect of meeting other Latino students.

“I got my Latino Students Association card, and I was so excited,” Paladino recalls. “But I discovered that because I was not fluent or hadn’t had [what was considered] the full Latino experience, I didn’t fit in well.”

Paladino, a professor and coordinator in the graduate studies in counseling program at Rollins College in Florida, may no longer stand out like he did in the white Connecticut enclave in which he grew up, but like most people of color, he is still subject to many assumptions and microaggressions. For instance, Paladino, who co-wrote and co-edited the book Counseling Multiple Heritage Individuals, Couples and Families (published by ACA), has been asked by a cashier at a department store whether he was his son’s nanny. Recently, as he stood in line at an amusement park, he was asked to settle a bet between two people he didn’t know. The wager? Whether Paladino was Puerto Rican.

These counselors’ stories provide a glimpse of the myriad forces — societal, familial and personal — that shape and challenge the lives of multiracial individuals. Counselors can play an integral role in helping their clients navigate these forces.

Identity intervention

That sense of not quite belonging — or even being told that they don’t belong — often starts early for multiracial individuals.

As Brew notes, as early as elementary school, multiracial children can begin experiencing microaggressions such as that question: “What are you?” Or, as in Brew’s case, these children might become the targets of racist taunts based on their actual or perceived ethnic backgrounds. For that reason, it is important for the parents of multiracial children to talk to them about race and racism from an early age, she says.

“Parents, in general, are reluctant to do that, but when parents do engage in it, the children are more prepared to handle comments,” Brew says. “There was an interesting study out of [the University of Texas at Austin] where they asked participants to talk with their kids about racism. When it came down to the wire, most parents dropped out of the study. It was simply too hard.”

Because the topic is so difficult and sensitive, counselors can be a tremendous asset to these parents by helping them to have conversations about racism with their children and with each other, Brew says. “This conversation needs to be explicit and purposeful,” she says. “The parents may need to work on thinking in inclusive ways rather than judgmental ways — the way we teach our students to respect differences. It’s the seed that helps teach children about their own culture as well.”

“I think it’s important for parents to start with very small children talking about skin color and how it’s different, but to give no meaning to color,” Brew continues. “We all see differences, and that’s fine. It’s when meaning is applied that differences become a problem. For biracial children, talking about how mommy and daddy — or mommy and mommy, or daddy and daddy — are different is also important to note, although, again, not giving meaning to those differences.”

“If the child is likely to experience racism or any other type of prejudice based upon differences, then [it’s] letting kids know that some people don’t understand differences and believe that people are bad based on how they look or how they dress, etc.,” she says. “Then when it actually happens, kids can feel safe to talk with parents, who should validate the child’s experience and help them make sense of it.”

It isn’t unusual for multiracial children to grow up, like Paladino did, in predominantly white neighborhoods. Even if these children don’t encounter bullying or overt racism, being one of the few (or perhaps only) children of color in an overwhelmingly white environment can exacerbate their feelings of not belonging. Counselors can help these children cope, Paladino says.

“I would want to continually validate what they are feeling and experiencing, which may be ‘otherness’ or not fitting in,” he explains. “At a young age, it may be difficult for [children] to fully grasp why they are experiencing these feelings, so I really want to be there for them in this part of the journey and allow them to ventilate feelings, thoughts and experiences.”

“For the parents, if they are a part of counseling or a parent consult, I would talk to them about what their child is feeling,” Paladino continues. “[I would] help them to experience empathy toward their child, talk to them about how to create a safe space for their child to talk and ventilate about how they are feeling and what they are experiencing, and help them look up children’s books as a way to talk about feeling different.”

School counselors — indeed all school faculty members — also play a critical role in helping multiracial children cope with racism and the struggle to feel included, says Taryne Michelle Mingo, an ACA member and former school counselor whose research focuses on marginalized populations. “I would [as a school counselor] develop a trusting relationship with the children and let them know that I can be a support system,” she says. For instance, she explains, if a child is being taunted or verbally abused, it is important for the child to view the school counselor as a safe person whom he or she can trust and feel comfortable going to for help.

One of the primary tasks for school counselors, Mingo says, is to get to know their students and make sure that everyone feels included. During her time as a school counselor, Mingo, who is African American, worked at a majority white school where only a small number of students were African American. Children of color aren’t typically used to seeing themselves reflected or represented in school materials, Mingo says, so she was careful about making sure there were dolls and books in her office that included children of multiple races. “Make sure that [these children] know they are visible,” she urges. “[That as counselors you are saying], ‘We know you are here.’”

When children who were feeling excluded showed up in her office, Mingo, who is now an assistant professor in the Counseling, Leadership and Special Education Department at Missouri State University, would engage them by asking them what they thought about themselves aside from what anyone else thought about them. She would have them describe themselves and ask them to draw a self-portrait. She would then go on to ask them what they liked to do and who their friends were.

If during the course of the conversation Mingo discovered that the child was feeling harassed or hearing negative comments, she would inquire where the child was and what was happening when he or she heard such comments. Mingo then asked what the child said or would have liked to say in response to those comments. Finally, she and the child would practice responding.

Mingo would also bring in the child’s teachers to make them aware of what was happening. When possible, she also liked to bring in the child’s parents or parent so that she and the parents could work together to more effectively support the child as a team.

Family tensions

In some cases, a child’s feelings of exclusion might be emanating from within the family itself. Not necessarily within the immediate family, but more often from the extended family, which might not have approved of the multiracial relationship in the first place, Paladino says. He notes that it was only in 1967 that it became legal to marry outside of one’s own race throughout the United States. That’s when the Supreme Court handed down a landmark decision in the Loving v. Virginia case that invalidated state laws prohibiting interracial marriage.

Brew has worked with multiracial couples and families facing the disapproval of extended family. “In terms of working with extended family racism, I first provide empathy to both partners,” she says. “Then I provide psychoeducation about the damage to self-esteem on children who listen to that type of talk. The biggest challenge is that so many minority families are hierarchical, so the adult child may not feel comfortable initiating these kinds of conversations. When it’s a Caucasian family member, then the relationship can often be less hierarchical, so the biggest challenge is just getting that partner to buy in and set limits with family members.”

“I haven’t had experiences with needing to cut off family members,” Brew continues. “[I] try to avoid that unless abuse is part of the picture. So, I help the clients manage their feelings about their own family members’ disapproval and try to offer support so that they eventually have the courage to confront their families. If they choose to confront, of course we practice that many times and prepare them for the worst possible outcome so they feel more confident.”

But even when there is no racial tension in the family, a multiracial person’s parents and other monoracial family members can never truly understand what it is like to be multiracial or multiethnic, Paladino says. “Validation is huge for this population,” he says. “They need support to figure out what they are, to allow them to be angry at family, angry at friends.”

MacDonald agrees. “My father, who is white, never understood why it was important for me to identify as biracial,” she says. “He views me as white and thinks I should identify as white. In a way, my white dad has always been a symbol for me of white culture because he also holds beliefs that don’t acknowledge institutionalized oppression and a belief that because we live in America, everyone has an equal opportunity to succeed — beliefs in which I do not share. Even as adults to this day, we do not speak of race, politics or privilege.”

Identity and acceptance

Ultimately, it is up to the multiracial individual to determine how he or she wants to self-identify. “A lot of clinical work is to help my clients articulate and identify what is from what culture so that they can make choices,” Brew says. “What feels right in different situations? Who am I, and what’s the right way to be?”

Counselors can play an important role by helping multiracial clients sift through all of their experiences and beliefs in the search for identity, says Mark Kenney, who helped write the multiracial counseling competencies and co-founded ACA’s Multiracial/Multiethnic Counseling Concerns Interest Network. He advises counselors to start by validating a client’s personal experiences and creating a safe environment for self-disclosure.

In some cases, counselors may need to help clients find resources, such as social groups or books, to explore their heritage because these clients didn’t have full access to part of their heritage growing up, Kenney says. He uses Barack Obama, who was raised by his white mother and grandparents, as an example. “His white family can’t tell him about being African American, and his father is Kenyan, so he can’t impart the African American experience,” Kenney notes.

Although identity is a pressing issue for many multiracial individuals, so is the question of feeling accepted or belonging. Kenney returns to the example of President Obama. Because of his phenotype, or physical appearance, most people automatically view Obama as African

President Barack Obama and First Lady Michelle Obama in September 2014. (Official White House photo by Pete Souza/via Flickr)

President Barack Obama and First Lady Michelle Obama in September 2014. (Official White House photo by Pete Souza/via Flickr)

American, and physical appearance is often an important factor that influences how multiracial individuals ultimately choose to identify themselves, Kenney explains. Given his lineage, Obama could have decided to identify himself as white, Kenney says, but because of the way he looks, society at large wouldn’t see or “accept” him that way, especially in our current racial climate. At the same time, Kenney continues, because Obama’s father was black but not African American (and because his mother was white), other people may not embrace Obama fully as being African American.

MacDonald says she sometimes struggles with feeling that she is a legitimate member of the multiracial community. “I am often viewed as white and, as a result, receive white privilege,” she explains. “So in many ways, I am an outsider to the multiracial community because I still receive privilege versus minority status.”

Again, counselors can help multiracial individuals reconcile these factors, but the process may not be smooth or easy. “Helping the person sort through their particular journey and come to their own decision about how they want to identify may put them in conflict with their family and their community,” Kenney notes.

With multiracial clients, Kenney likes to use solution-focused and narrative therapy. With narrative therapy in particular, clients can write a new story of their identity, he says. Kenney also stresses the importance of counselors familiarizing themselves with multiracial identity models so they are aware of all the factors involved in a person choosing an identity.

Because individuals who are multiracial might not be or feel fully accepted by any of their racial groups, counselors should help them seek out individuals who possess similar backgrounds, Kenney says. If organizations for multiracial individuals aren’t readily available in their communities, counselors might consider forming groups — perhaps using the group therapy model, but for social rather than therapeutic purposes, Kenney says.

Kenney and Paladino also recommend bibliotherapy as an effective intervention with multiracial clients who are struggling with their identity or sense of belonging. Paladino says he personally found Half and Half: Writers on Growing Up Biracial and Bicultural, edited by Claudine Chiawei O’Hearn, very helpful in his journey.

No assumptions

All of the counselors interviewed for this article caution against assuming that individuals who are multiracial have come to counseling because of their multiracial status. At the same time, Brew and MacDonald say it is important not to automatically assume that no connection exists between the person’s presenting problem and his or her multiracial status. After all, being multiracial does exert influence on clients’ lives, just as do other factors bound up in identity, such as being female, having a disability or identifying as lesbian, gay, bisexual or transgender.

Catherine Chang, an ACA member whose research specializes in multicultural issues, believes that society needs to change how it identifies people. Counselors can help, she says, starting with their intake forms and how they designate racial background.

“We force people to check a box,” Chang says. “I’m 100 percent Asian and married to a Caucasian man. My children have to check two separate boxes — white, Asian. They can’t check multiracial or biracial.”

Chang urges counselors to offer an option for multiracial individuals on intake forms and to also leave space for clients to fill in what they feel their background is. Paladino agrees, noting that check boxes don’t encompass multiple heritages such as being black and also being Jewish.

Finally, Chang says that it is important for counselors to examine their own heritage and how that background affects who they are and how they interact with individuals from other groups and races.

 

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Related reading: See Counseling Today‘s online article about transracial adoption, “Adopting across racial lines” wp.me/p2BxKN-4xn

 

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Additional resources

To learn more about the topics addressed in this article, take advantage of the following resources offered by the American Counseling Association:

Competencies (counseling.org/knowledge-center/competencies)

ACA Interest Networks and Divisions

Books (counseling.org/bookstore)

  • Counseling Multiple Heritage Individuals, Couples and Families, written and edited by Richard C. Henriksen Jr. and Derrick A. Paladino
  • Culturally Responsive Counseling With Latina/os by Patricia Arredondo, Maritza Gallardo-Cooper, Edward A. Delgado-Romero and Angela L. Zapata
  • Counseling for Multiculturalism and Social Justice: Integration, Theory and Application, fourth edition, by Manivong J. Ratts and Paul B. Pedersen
  • Multicultural Issues in Counseling: New Approaches to Diversity, fourth edition, edited by Courtland C. Lee
  • Understanding People in Context: The Ecological Perspective in Counseling, edited by Ellen P. Cook
  • Experiential Activities for Teaching Multicultural Competence in Counseling, edited by Mark Pope, Joseph S. Pangelinan and Angela D. Coker

Podcasts (counseling.org/continuing-education/podcasts)

  • “Queer People of Color” with Adrienne N. Erby and Christian D. Chan
  • “Microcounseling, Multiculturalism, Social Justice and the Brain” with Allen Ivey and Mary Bradford Ivey
  • “Multiculturalism and Diversity: What is the Difference? Is Not Counseling … Counseling? Why Does it Matter?” with Courtland C. Lee

Webinars (counseling.org/continuing-education/webinars)

  • “Why does culture matter? Isn’t counseling just counseling regardless?” with Courtland C. Lee

VISTAS Online articles (counseling.org/continuing-education/vistas

  • “The Invisible Client: Ramifications of Neglecting the Impact of Race and Culture in Professional Counseling” by Issac Burt, Valerie E.D. Russell and Michael Brooks
  • “Appreciating the Complexities of Race and Culture” by Ria Echteld Baker
  • “Counselors’ Multicultural Competencies: Race, Training, Ethnic Identity and Color-Blind Racial Attitudes” by Ruth Chao
  • “Enhancing Multicultural Empathy in the Classroom and Beyond: A Proposed Model for Training Beginner Counselors” by Jorge Garcia, Gerta Bardhoshi, Matthew Siblo, Sam Steen and Eileen Haase
  • “Ethnic Minority Clients’ Perceptions of Racism-Related Stress in Presenting Problems”
    by Ruth Chao
  • “Interracial Adoption and the Development of Cultural Identity” by Kimberly Kathryn Thompson

Practice Briefs (counseling.org/knowledge-center/practice-briefs)

  • “Racial Microaggressions” by Cirleen DeBlaere, Terrence A. Jordan II and David G. Zelaya

 

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editorct@counseling.org

 

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

The relationship as client

By Laurie Meyers September 22, 2016

Among the most common difficulties that bring couples to counseling are infidelity, financial problems, sex and intimacy issues, parenting challenges and ongoing tensions with the in-laws. Each of these problems has its own unique characteristics, but according to couples counselors, they tend to share a similar root cause — namely, lack of communication. The challenge for couples counselors (and their clients) is to identify how communication went awry — or if it ever truly existed in the first place — and then work to reestablish it.

Couples counseling is fundamentally different from individual counseling, says Paul Peluso, past president of the International Association of Marriage and Family Counselors, a division of the American Counseling Association.

“Too often, counselors think that couples counseling is ‘individual counseling times two,’ and they conduct individual counseling with each person, while the other partner observes,” Peluso says. “That really isn’t couples counseling. Instead, with couples counseling, you have not just branding-images_inkhearttwo perspectives in the room that you have to balance, but you have the … relationship that you are working with. In fact, it is the couple’s relationship that technically is your client, not the individuals in the couple.”

Having a relationship as the client instead of an individual makes it much more challenging to build a therapeutic alliance, says Barbara Mahaffey, a licensed professional clinical counselor and ACA member who practices in Chillicothe, Ohio. The relationship is not just an entity, but rather two separate people who have different thresholds for opening up and trusting, she explains. Couples also come in with different goals and expectations. Mahaffey, who specializes in counseling couples and families, says her task as a counselor is not just to address these goals and expectations, but to help the couple discover how they can reconcile their personal expectations and establish new goals that will allow them to move forward as partners.

“Couples will come in and want to fight over who is right and who is wrong in the relationship,” Peluso says. “It is the couples therapist who has to sell the idea that no one is wholly ‘right’ or wholly ‘wrong.’ Paradoxically, neither is to blame and both are to blame — in the technical sense — for the state of the relationship at the same time. Both have played a role in setting up the conditions for the relationship. So the focus is on how each person’s behavior and reactions to [the] other affect the couple’s relationship. If each person wants to be in the relationship, then they have to take responsibility for how their behavior impacts the health of the relationship. And this is very different than individual counseling.”

Confronting infidelity

Unfortunately, the catalyst that most often pushes couples into a counselor’s office is also one of the most difficult issues to move past.

“The single most common issue that brings couples into therapy is infidelity,” says Peluso, a licensed marriage and family therapist (LMFT) who has written several books about both infidelity and couples counseling. “Over the last 20 years, researchers have demonstrated that this is the most common presenting concern, and if it is not revealed initially, it is often disclosed in the course of couples therapy. Infidelity can take many forms, from sexual to nonphysical intimacy, and it now includes relationships online.”

“In terms of who cheats, researchers have found that women are just as likely as men to participate in infidelity,” Peluso continues. “As a result, practitioners have to know how to deal with the complex and often devastating issues that accompany infidelity. Unfortunately, when couples counselors are asked about it, they overwhelmingly say that it is the topic they feel least prepared to treat.”

Amber Lange, a licensed professional counselor who owns and practices at Bedford Health, a group practice in Lambertville, Michigan, can attest to the high demand for infidelity counseling. Her practice has become known for specializing in issues surrounding infidelity and betrayal. Initially, the sheer need for counselors knowledgeable about and willing to tackle this particular relationship threat astounded her. “I’ll never be out of a job [as an infidelity specialist],” she says ruefully.

Among couples for whom the act of infidelity is fresh, the nonoffending partner is typically experiencing acute stress and may even have symptoms that resemble posttraumatic stress disorder, Lange says. The offending partner, on the other hand, is typically feeling beaten down because he or she has repeatedly been asked blunt questions that shine a direct light on his or her indiscretions: What did you do? Where? How much money did you spend?

In cases in which the infidelity is years in the past, the core counseling issue more often involves a lingering lack of trust, Lange says. “The nonoffending partner [may have] forgiven the offending partner, but they have never rebuilt trust,” she explains. “So the nonoffending partner is hypervigilant about trust and the [possibility of the] offending partner reoffending.”

If the act of infidelity is recent, Lange helps the couple work through their “why, who, where, how” stage. “I talk about the idea of how you can’t ‘unknow’ something once you know it,” says Lange, a professor of counseling at Capella University. “There’s a lot of knowledge that you can gain that may further traumatize you, such as the sexual positions that your partner was in with someone else.”

Clients may also wonder if their partner did things with another person that the nonoffending partner refused to do. If this information is disclosed, Lange explains, it can lead the nonoffending partner to do things he or she is uncomfortable with in an attempt to please the offending partner.

Instead of attempting to get answers to questions that can further damage the relationship, Lange encourages the nonoffending partner to ask structured questions such as: When did you start having sex? When did you stop? Did you have unprotected sex? These types of questions provide information that the nonoffending partner needs to know, Lange says.

The next phase of Lange’s therapeutic approach involves narrative therapy. As part of this stage, Lange might ask couples who delayed getting therapy after the infidelity to briefly touch on information about the affair as a way to see if there are lingering questions. This process also helps Lange to assess the strength of the couple’s bond.

The story of ‘us’

Regardless of whether the couple is confronting a recent infidelity or the infidelity happened years in the past, constructing the story of their relationship represents the core of the healing process, according to Lange. Couples build the narrative to gain a clearer understanding of how and when the cracks in their relationship developed, she explains. They talk about the beginning of their relationship and explore how they interacted. Were they friends and true partners? What happened that started pulling them apart?

“Life” — deaths, births, work, money and so on — is usually the answer to that second question, Lange says. In addition, people typically change over time, which further alters the nature of the relationship, she notes. All of these factors in combination can make a relationship vulnerable to disruption. Add in misperceptions and unmet expectations, and once tiny relationship fissures can turn into large cracks that cause couples to drift apart.

Among the most common life events that can start to pull some relationships apart is the birth of a child, Lange says. “Before the birth, couples were able to spend all their time and energy and money on each other. After the birth of a child, ideally, you love that child and invest all of that [time, energy and money] in parenting and child rearing — which is not bad, but [couples] come into my office, and they haven’t been on a date in three years.”

In addition to not making time for the romantic relationship, the couple may be trapped in patterns that are actively pulling them apart, Lange says. “You’ve been great parents, but the mother is staying home or working and raising kids at the same time, the father is working and overworking to pay for the mortgage and save for retirement — those kinds of things can hurt a relationship,” she says.

When a couple stops talking to each other, it creates a gap, and it is tempting to fill that gap with other people or activities, Lange notes. Partners may begin to betray each other in different ways, whether it is spending time on social media instead of with each other, watching pornography or working long hours, she says. “In the process, we’ve let the relationship go awry,” Lange observes.

But this risk of unraveling is not exclusive to couples with children. Those who get married or enter into domestic partnerships too quickly upon meeting or when they are very young are also particularly vulnerable, Lange says. For example, those who form romantic relationships in their teens or early 20s are in the midst of experiencing significant personal development. This may not happen at the same rate for both partners, eventually leaving them feeling as if they don’t know each other, Lange explains. Likewise, people who get married or form a domestic partnership in the matter of a few weeks have not typically had enough time to establish a strong base of friendship. Over time, it’s not uncommon for them to realize that they don’t even like each other, Lange says.

Lange asks clients not to make a decision about whether to stay together until after they have gone through the process of identifying what went wrong. Then, if they choose to stay together, Lange helps them start to discuss how to protect the relationship going forward. This typically includes setting aside time to talk with each other more frequently, being intentional about making time for dates and even going on vacations without the kids. But it also involves each partner identifying the behaviors in which he or she engages that play a role in pulling the relationship apart.

For example, Lange recounts something that a client recently shared. “One of the things that I have recognized about myself over the past six months is that I tend to withdraw,” the client told her. “When my partner and I got into an argument, I went away, slept in the kids’ room and wouldn’t talk. I would work 85 hours a week. Even when I wasn’t in the office, I was checking my email.”

In essence, Lange says, the client just wasn’t “there” in the relationship. Other people do the same thing by burying themselves in hobbies such as sports or scrapbooking. As a result, they end up spending more time with friends or with hobbies than they do with their partner and family, Lange says.

The process of building the couple’s story in counseling and finding the cracks and vulnerabilities is a long one. For the first four to six weeks, when a couple is still going through the initial trauma phase of the infidelity, Lange has them come to counseling every week. Once a couple moves on to the storytelling stage, she has them come to counseling only about once per month, in part because she feels that much of the processing and healing needs to take place between sessions as the couple slowly rebuilds the relationship.

“They have to have time to figure out things … how to be in relationship, how to recreate their friendship and how to build [new] good memories,” Lange says. During the process of rebuilding the relationship, trust is also being reestablished and forgiveness is being granted. Then the couple can move forward, she explains.

Ideally, the couple will also identify potential problem areas and reach compromises on how to address those issues. For example: “You say I can’t work 90 hours a week, but we need money, so how are we going to figure that out? … This is [our] story. Here’s the way we go forward. Here’s what we need to do.”

Symptom vs. problem

Brian Canfield, a past president of ACA, also says that infidelity is the event that most commonly brings couples into his office. But he believes infidelity is always indicative of other underlying problems in the marriage or relationship.

“I view an affair not as the problem but as a symptom,” he says. “An affair is like malarial fever. It’s uncomfortable, but it’s not the fever itself that’s going to kill you — it’s the disease.”

Canfield believes that if a counselor addresses the underlying issue first, it will help to stabilize the couple, which will then allow them to deal with the ramifications of the infidelity. “You [the counselor] have to assess if there is a commitment and desire to save the relationship,” says Canfield, an LMFT whose practice has offices in Louisiana, Arkansas and Florida. “Trust and betrayal, that’s not where you put the spotlight. The trust will return once you stabilize the relationship.”

Canfield starts by asking the couple what they want out of the counseling process and their relationship as a whole. “What would you like to see happen? If it is possible to salvage the marriage, would you be willing?” Canfield asks. “A lot of people want to know why [the affair happened], but here is where we are. Where do you want to be? If you were going to redesign marriage, how would it look?”

Canfield says financial difficulties are the most common underlying issue that couples bring into his office. In his experience, there is so much shame surrounding finances that most couples would rather talk about the details of their sex lives than money. He frequently encounters situations with couples in which one partner has been maintaining a hidden bank account or run up the balance on their credit cards without the other partner knowing. He tells couples that part of the counseling process involves full disclosure.

“A lot of couples are in tremendous denial,” Canfield says. “They don’t know how much debt they are in, what their bills are or have a good picture of how much income they are bringing in.”

Sometimes people feel entitled or convince themselves that it’s OK to buy what they want regardless of how it affects their spouse or partner. They tell themselves that they work hard and that they deserve it. Canfield sees part of his role as helping to bring clarity to these situations to encourage better choices.

“The other spouse may say that if this doesn’t change, I will exit the marriage for my own survival. Which circumstances are more important? Keeping the marriage or continuing to spend?” he asks.

Canfield doesn’t try to play the part of financial adviser to couples (although he does recommend that couples seek professional financial advice elsewhere if needed). Instead, he helps couples recognize their need to possess a clear picture of their financial situation and to develop a reasonable budget.

“It’s a matter of priorities and trade-offs,” he says. “The key as a couples counselor is to have the couple work together as a team. Most couples, when they work as a team, can find common ground.”

Canfield emphasizes that as a couples counselor, it’s not up to him to dictate how much a couple will spend on their priorities. Instead, his focus is simply on making sure that they have agreed on a plan going forward.

Once the underlying issues have been addressed, Canfield helps the couple deal with what he calls the “moral disparity” in a relationship in which infidelity has occurred. The nonoffending partner may feel like he or she has the higher moral ground, but to move forward, the couple must try to reach a “mutual amnesty,” Canfield says.

This involves a delicate balance. Canfield tries to make the couple aware that the infidelity occurred because of the underlying problems — to which they both contributed — that were straining the relationship. However, he always makes it clear that it is not the fault of the nonoffending partner that the other partner cheated. Yes, they both contributed to the relationship’s problems, but the offending partner chose to act out by having an affair.

Matters of miscommunication

Mahaffey, an associate professor of human services technology at Ohio University–Chillicothe, finds that relationship difficulties usually involve a significant degree of miscommunication, which is exacerbated by a number of factors. She helps couples understand how communication can get mixed up by explaining the pieces of a “miscommunication model” that she has devised.

Mahaffey starts by asking both partners to list all of the traits they possess that are different from their partner’s traits. She then takes these lists and draws two people facing each other. This represents two people talking, whereas the lists represent their different — and sometimes conflicting — points of view. Mahaffey often also draws a “family rule book” between the two figures. This represents how a person’s family of origin can affect the way he or she interprets interactions with a partner. Mahaffey often asks couples about their family backgrounds and experiences to illustrate the influence of the family of origin.

Mahaffey will then ask both partners to think about all the times they asked for something and didn’t receive what they wanted from their partner. As they voice these details, it’s not unusual for one partner to exclaim, “You never said that!” Typically, the case is not that either partner is lying, Mahaffey says. Rather, it’s that one of the partners has not been phrasing the requests in a way that effectively communicates what he or she needs, Mahaffey explains. She also informs the couple that humans think at about 500 words per minute but cannot speak more than 125 words per minute, meaning there is ample opportunity for the intended message to get lost.

Other complicating factors in communication include different coping styles (such as one member of the couple shutting down verbally or retreating physically or emotionally during times of stress), the fact that women often process information differently than men and the daily anxieties of life, Mahaffey says. For example, it’s hard for a couple to communicate effectively when one or both partners are stressed about finances, work or the car breaking down.

The last part of Mahaffey’s model entails explaining how words themselves — or how people define them — can get in the way. For example, Mahaffey might ask a couple, “What’s the definition of love? Is it that supper is on the table when I come home? Or liking to snuggle? Or texting 60 times a day?”

At this point, Mahaffey has the couple use “I” statements and talk about what needs they feel are being unmet. One partner might say, “I like to have help with housework.” The other partner might note that the request usually comes during a football game or while engaged in something else that he or she enjoys doing. At this point, Mahaffey might ask if the partner would be willing to provide help either before or after the game. This exercise highlights just one example of an area of possible compromise. The larger point is that the couple needs to sit down and talk about what they need from each other and how those needs can be met, Mahaffey says.

Intimate partner violence 

All counselors, but couples counselors in particular, should be looking for signs of intimate partner violence (IPV) among their clients, asserts Ryan Carlson, an ACA member and couples counselor who has done research on screening methods for IPV.

Because IPV is such a prevalent societal problem, all counselors — knowingly or unknowingly — will encounter clients who have experienced or are currently experiencing violence at the hands of their partners, Carlson says. According to data gathered in 2011 and published in 2014 by the Centers for Disease Control and Prevention, more than 1 in 4 women and more than 1 in 10 men in the United States have in their lifetime experienced sexual violence, physical violence or stalking by an intimate partner.

Providing counseling in the presence of such interpersonal violence can be dangerous, not just to the victim but also to the counselor, says Carlson, a licensed mental health counselor practicing in Columbia, South Carolina. That is a primary reason it is important for counselors to be alert to the signs of IPV and to have a protocol to follow should a client be a victim.

Perhaps the most beneficial thing counselors can do is to get connected to the people Carlson calls the “real experts” on this issue — those who work at local domestic violence shelters. “Most of what I have learned [about IPV] has come from domestic violence advocates,” he acknowledges.

Not only can these advocates help counselors assess whether it is safe to work with a couple in which IPV is a reality, but they also stand ready to assist clients who are looking for help, says Carlson, an assistant professor of counselor education at the University of South Carolina.

Carlson says he uses the term IPV because it is more inclusive than domestic violence. There is an IPV continuum, and domestic violence is on the extreme end of the spectrum, representing the most severe cases that involve, as Carlson puts it, “power and control,” as opposed to nonlethal violence or verbal abuse. From Carlson’s perspective, it is not safe to try to conduct counseling in those cases involving power and control.

Carlson advises counselors to use a formal screening tool for IPV at intake but says there are other red flags to look for, including a client’s unwillingness to take responsibility for actions. “Control over finances or transportation is [also a] red flag,” he continues. “Is one partner restricting access to cell phones, finances, the car, who the other partner can interact with? … Look for body language. Does one partner consistently look to the other when they answer questions? Is it permission seeking? Is there inconsistency in their answers? For example, as part of a meeting to determine whether or not a couple would want to participate in a research study I was doing, I asked about income. The husband gave me an answer, but when I met with the wife separately, she said the husband wasn’t really working and that she wasn’t allowed to talk about that.”

This one disparity turned out to be an indication of severe domestic violence. Carlson followed his protocol and was able to get help for the victim.

What does a protocol look like? Carlson says he has a formal memorandum of understanding with the local domestic violence shelter saying he can call at certain hours when he has a need for consultation. The memorandum also states that he will not provide identifying information about the client, only basic relevant information. This includes the presenting problem and any context he feels is important. The consultant can then advise him on whether the couple’s case might be a power-and-control situation. In those instances, Carlson must find a way to offer help to the victim without tipping off the partner who is engaging in the abuse.

With all of the couples Carlson counsels, his regular practice is to meet briefly with each individual separately at the beginning of each session. This is primarily so that he can get each partner’s point of view independently on the difficulties the couple is experiencing, but it also provides him with a chance to provide contact information for the domestic violence shelter if circumstances warrant. Carlson and the partner who is the target of the abuse may even call the shelter together.

In some cases, however, the victim of the abuse is not ready to leave the relationship. Carlson say many counselors may have a hard time relating to that. “We think we need to get the person out of the relationship immediately, but [we] need to do it safely,” he cautions

The victim has typically been living under abusive circumstances for years and may not yet have reached a crisis point, Carlson explains. Again, he uses consultation with his domestic violence resources to help him navigate this terrain. Regardless of whether the victim is ready to leave, Carlson says the average counselor should not try to continue providing services in these power-and-control cases. Telling the couple that he feels this particular modality will not work for them has proved to be a successful way of terminating treatment without escalating the problem of abuse, he says.

Lynn Linde, senior director of the ACA Center for Counseling Practice, Policy and Research, adds the caveat that counselors should make sure their states do not require them to report suspected cases of IPV under mandated reporting laws.

There are IPV cases for which Carlson thinks couples counselors are qualified to help. These involve lower lethality or “situational couple violence” (as opposed to one partner begin generally aggressive outside of the relationship as well). In such instances, a couple’s arguments may get out of hand and they may engage in behaviors such as pushing or throwing things at each other. “This can be dangerous, but it’s not as dangerous as choking or using a weapon,” Carlson says. However, he says, it is important for the couple to acknowledge that this behavior is unhealthy and to show a willingness to learn more appropriate ways to interact. It’s also essential that neither partner is afraid of the other, Carlson stresses.

In contrast, partners who engage in power-and-control tactics usually show little or no remorse and may exhibit antisocial-type behavior, Carlson explains. In fact, he says, studies have shown that when engaging in the abuse, these types of offenders typically experience a drop in heart rate rather than an escalating heart rate that is typically associated with anxiety over one’s situation or actions. Carlson also notes that whereas research indicates that men are almost always the perpetrators of power-and-control types of IPV, situational IPV is gender neutral.

None of this information constitutes a foolproof method for deciding whether it is safe for a counselor to work with a couple with a history of IPV. That’s why Carlson continues to do research on screening methods that are better at identifying the presence of violence among couples and where on the spectrum of severity that violence falls.

“Getting it wrong can be very dangerous,” Carlson concludes.

Counseling LGBTQ couples

Although the issues that bring lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) couples into counseling are generally the same as those that affect heterosexual couples, the legalization of same-sex marriage has raised some issues unique to LGBTQ relationships, say counselors who work with this population.

“There is a tremendous validation both from the legal system and from society upon their relationships,” says John T. Super, an LMFT who is also a clinical assistant professor of counselor education at the University of Florida. “This validation can provide an emotional confidence or boost surrounding a same-sex relationship that lessens the perceived stigmatization that has occurred. Additionally, since the Supreme Court decision [legalizing same-sex marriage], we have seen a large number of those in long-term relationships choosing to marry and report feeling equality to traditional marriages.”

Although the Supreme Court’s decision is a huge advancement for the LGBTQ community and has given many couples the opportunity for which they have long waited, actually getting married has not been absent of negative consequences for some couples, says Super, a member of ACA. “Clients have explained [that] when they announced their marriage … it was in many ways similar to the coming-out process in that those who are choosing to marry and are in same-sex relationships may face resistance from friends and family as they legalize the relationship,” he explains. “I have heard clients say that their friends and family accepted their relationship, but when they choose to marry, the thought of the same-sex couple entering into a legal marriage is a line the friends or family are not comfortable crossing.”

Counselors have an important role in helping same-sex couples navigate the resistance they may face when they decide to get married, agrees Joy Whitman, a past president of the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling, a division of ACA. Amidst the joy of getting married, there may be feelings of hurt and loss from being rejected all over again by certain individuals or segments of society, she says. Counselors can help couples grieve and process this loss.

According to Whitman, who previously worked as a couples counselor, marriage can also exacerbate a common problem in same-sex relationships: unequal comfort levels with being “out.” Marriage can make the partner who is less “out” feel especially vulnerable, she explains.

Counselors should also be aware that for the first time, LGBTQ couples are facing divorce, Whitman says. Not only is this a new experience, but the need in many cases to stand up in court and disclose intimate relationship details can be particularly disconcerting for clients in same-sex relationships, she says.

Super and Whitman also note that counselors need to be aware of the generation gap among different LGBTQ couples. “Couples who are in their 20s experienced a very different level of social acceptance than couples in their 50s or older,” Super points out. “This generational difference can be important to understand when determining the levels of internalized oppression the individual or couple has experienced.”

Despite these issues and other issues that are specific to the LGBTQ community, Super and Whitman emphasize that couples counseling is couples counseling. Peluso, an associate professor of counselor education at Florida Atlantic University, agrees.

“In many respects, the practice of couples counseling shouldn’t change that much,” he says. “Focusing on the relationship means taking the relationship as it is created by the partners involved. The only judgment that the couples counselor is making is, ‘Is this healthy for you right now?’ and then seeing how the couple can change that. That is fairly universal.”

 

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Additional resources

To learn more about the topics addressed in this article, see the following select resources offered by the American Counseling Association.

 

Books (counseling.org/bookstore)

Podcasts (counseling.org/continuing-education/podcasts)

  • “Love and Sex and Relationships” with Erica Goodstone

Webinars (counseling.org/continuing-education/webinars)

  • “Crazy Love: Dealing With Your Partner’s Problem Personality” with W. Brad Johnson
  • “The Secrets to Surviving Infidelity” with Scott Halzman

VISTAS Online articles (counseling.org/continuing-education/vistas)

  • “Five Counseling Techniques for Increasing Attachment, Intimacy and Sexual Functioning in Couples” by Elisabeth D. Bennett, Jaleh Davari, Jeanette Perales, Annette Perales, Brock Sumner, Gurpreet Gill & Tin Weng Mak
  • “Helping Couples Reconnect: Developing Relational Competencies and Expanding Worldviews Using the Enneagram Personality Typology” by Thelma Duffey & Shane Haberstroh
  • “Loving Kindness Meditation and Couples Therapy: Healing After an Infidelity” by Laura Cunningham & Yuleisy Cardoso
  • “Supporting Same-Sex Couples in the Decision to Start a Family” by Debbie C. Sturm, Erika Metzler Sawin & Anne L. Metz
  • “Working With Intercultural Couples and Families: Exploring Cultural Dissonance to Identify Transformative Opportunities” by Cheryl L. Crippen
  • “Working With Sexual Addictions in Couples Therapy” by Sara L. Wood

Practice Briefs (counseling.org/knowledge-center/practice-briefs)

  • “Counseling Couples With a Trauma History” by Catherine J. Brack & Greg Brack

ACA Divisions

  • The International Association of Marriage and Family Counselors helps develop healthy family systems through prevention, education and therapy (see iamfconline.org).
  • The Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling seeks to promote greater awareness and understanding of LGBT issues and improve standards and delivery of counseling services provided to LGBT clients and communities (see algbtic.org).

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editorct@counseling.org

 

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

 

Getting unstuck

By David Flack March 28, 2016

Andrew never knew his father. At age 4, he witnessed the death of his mother from an overdose. She was heroin dependent, and they were living in a car at the time. After her death, Andrew entered the foster care system. Between the ages of 4 and 15, he experienced more than a dozen different placements. Not surprisingly, with each move, his behavior became increasingly problematic.

At age 9, Andrew started drinking alcohol. By age 11, he was using alcohol and marijuana regularly. He discovered meth as a 13-year-old and went to inpatient care for the first time. He ran away after four days. When he was 15, he ran from the group home where he was living.

When Andrew entered treatment at age 16, he was on probation and had just moved into a transitional living program after several months on the streets. When he started treatment, he met Branding-Images_Unstuckthe criteria for multiple substance use disorders. He also had pre-existing mental health diagnoses that included posttraumatic stress disorder (PTSD), attention-deficit/hyperactivity disorder, conduct disorder and major depressive disorder. At that time, Andrew said he had no interest in stopping his substance use because “that’s not a problem for me.”

In his treatment journal, Andrew wrote, “Lots of times I feel like I’m living in some kind of black hole. I’m alone, but not really, because everything’s there, because I just can’t escape it no matter what I try. It’s black there, because that’s what black holes are, right? But black is really all the colors at once, every single one of them. And that’s too many damned colors if you ask me.”

Understanding the stuckness

Very few teenagers enter substance abuse treatment by choice. They show up due to legal mandates, school requirements, family pressure or other external reasons. Often they see treatment as the least bad choice — only slightly better than detention, suspension or homelessness. Like Andrew, these teens often appear unwilling or unable to do things differently, even though their current behaviors are clearly causing problems. In other words, they’re stuck.

I propose that our primary task as counselors is to help these teens get unstuck — not behave better, fulfill mandates or even stop using substances. We can hope those other things happen. I certainly do. However, it seems to me that those changes can occur only when an individual gets unstuck.

When helping teens get unstuck, we need to maintain a developmental perspective as counselors. Various developmental models exist, with most including a progression of stages that individuals move through, and each stage featuring specific tasks to be accomplished. The primary stage-specific tasks for adolescence are generally considered to be developing identity and establishing autonomy. As part of establishing autonomy, it is normal for adolescents to question, rebel against and ultimately reject the plans of authority figures, including the most well-intended plans of professional helpers.

Sometimes, those well-intended plans lead to reactance, which is a tendency to resist influences perceived as a threat to one’s autonomy. Many adolescent treatment programs are designed in ways likely to exacerbate reactance. We tell adolescents what, when, why and how. In residential programs, we restrict personal items. In wilderness programs, we often take away everything. Then we wonder why participants are unsuccessful. Worse, we blame them — declaring them in denial, resistant to treatment, unwilling to engage or simply noncompliant. Instead of helping, we’ve increased their stuckness.

Reactance can be exacerbated by what I think of as developmental debt. Most developmental theories state that if a person doesn’t successfully complete the tasks for a specific stage, then he or she remains in that stage. It seems to me that this might not be accurate. Instead, sociocultural and biological factors keep pushing individuals forward, even when tasks at another stage are unresolved or only partially completed.

With every push forward, an individual becomes less likely to complete the next stage. This leads to an ever-growing developmental debt. Much like with a credit card that’s never fully paid off, the person not only will always have a balance due, but he or she will get further behind each month.

With this developmental perspective in mind, I propose five strategies for fostering change with teenagers who have co-occurring disorders. Inspired by motivational interviewing, stages of change, narrative approaches and existential psychotherapy, I have found these strategies useful for helping this population to overcome rigid thinking, get unstuck and start moving forward.

Slow down

Traditionally, drug treatment programs have assumed that anyone entering services is ready to get and stay clean. This simply isn’t true. Change is a process, not an event. When we slow down, we’re able to help participants move through that process. Developed by James Prochaska, John Norcross and Carlo DiClemente, the stages of change is an evidence-based transtheoretical model that identifies five steps in the process of change:

  • Precontemplation: The person doesn’t believe he or she has any problems related to the target behavior, so the person sees no reason to make changes. To help participants in this stage, we can focus on building a therapeutic alliance, validate the participant’s lack of desire to change and provide objective information.
  • Contemplation: The person is considering the possibility that a problem might exist but hasn’t yet decided if change is necessary. To help participants in this stage, we can explore the pros and cons of continuing to use substances, gently identify contradictions, help make links between substance use and mental health challenges, and provide opportunities to imagine or experience alternatives.
  • Preparation: The person has identified a problem related to the target behavior and is deciding what to do next. To help participants in this stage, we can encourage small initial steps or experiments, continue to explore and solidify motivation for change, and help eliminate obstacles to change.
  • Action: The person has decided to change the target behavior, has developed a plan and is now putting that plan into action. To help participants in this stage, we can explore ways to implement change, provide support, build self-efficacy and remain solution focused.
  • Maintenance: When the new behavior has become habit, the person has entered this stage. I propose that six months of sobriety is a good milestone for this. To help participants in this stage, we can provide ongoing support, continue to explore real or perceived obstacles and foster resiliency.

In addition to these five stages, there’s Recycle, which occurs when a participant reverts to behaviors from an earlier stage. When a participant recycles, many helpers blame the person’s lack of skills, situational factors or unwillingness to change. Extenuating circumstances may certainly be present, but it seems to me that recycles occur because we push participants into the action stage too quickly. As such, recycles are potent reminders that we should slow down and revisit earlier stages, looking for unfinished or overlooked business.

Identify their motivators

Teens often enter services believing that they’re free of problems or that their only problem is something external. It may not seem like success to some, but the change process has begun when teens report treatment as the least bad option, state that their only problem is that others think there’s a problem or make similar comments. These may not be the motivators we desire for participants, but change requires meeting them where they are at, not where we want them to be.

We can help clients discover and deepen their motivators by using the “Five R’s” from William Miller and Stephen Rollnick’s motivational interviewing:

  • Relevance: Why is change important?
  • Risks: What are the risks of changing? What are the risks of not changing?
  • Rewards: What will you gain from change?
  • Roadblocks: What are the obstacles to change?
  • Repetition: Review these elements at each session.

Sometimes, to help participants solidify their motivators for change, we need to assist them in developing problem-recognition skills. We can do this by exploring what defines a problem; nurturing mindfulness; and creating an inclusive, nonjudgmental treatment environment.

Approaches from narrative therapy can also be helpful. Teens with co-occurring disorders typically enter treatment with problem-saturated stories. These tales of stuckness have become the defining stories for their lives. Help them discover new stories and further increase problem-recognition skills by:

  • Externalizing the problem: Instead of “having” a problem or “being” a problem, assist participants to view problems as existing outside themselves. This helps remove pressures rooted in blame, shame and defensiveness. Take
    this even further by encouraging participants to think of problems as characters in their stories.
  • Seeking exceptions: We build and sustain problem-saturated stories by ignoring times when the problem wasn’t in control. Seeking exceptions involves assisting participants to discover those ignored times. These exceptions hold
    the keys to change, so explore them in great detail.
  • Reauthoring stories: Once exceptions have been discovered, participants can start reauthoring their problem-saturated stories. Reauthoring gives them the opportunity to create new, more empowering stories with plots that focus on moving forward.

Some teenagers are so stuck that they’re unable to identify any exceptions to their problem-saturated stories. In these cases, it can be useful for counselors to add a fourth approach to those cited previously: creating exceptions. One way for these teens to break the cycle of stuckness is to try something new. I’ve had participants explore belly dancing, glass blowing, rock climbing, rugby, hand drumming and much more.

Expect ambivalence

As I’ve noted, the change process has begun when a teen’s thinking moves from “I don’t have a problem” to “My only problem is that other people think there’s a problem.” When this occurs, the participant has moved into the contemplation stage of change. This stage is about ambivalence, which can be defined as simultaneously believing two seemingly contradictory ideas.

Ambivalence is common for all teenagers, who desire the privileges of adulthood while retaining the comforts of childhood. In the case of substance-using teens, there is often another, more complex layer — wanting to fix their problem while continuing to use. Andrew described this ambivalence well: “Using has really messed up my life, but I don’t think I’ll ever stop. When I’m high, the bad feelings go away. I don’t think about the past, and I don’t care about the future. For a little while, my brain shuts up and I can pretend everything’s OK.”

Some professional helpers focus solely on the reasons to stop using, perhaps believing that any discussion about the possible benefits of drug use will be seen as an endorsement. This simply isn’t true. Helping youth such as Andrew get unstuck requires a sincere, nonjudgmental exploration of both the pros and the cons of substance use. Here are a few other ideas for resolving ambivalence:

  • Normalize the process. Change is hard. It conflicts with deeply ingrained behavioral patterns and neural pathways. It requires us to ignore the stories we tell about who and what we are. It requires us to face the unknown. Because change is hard, we’d rather stick to the known, even when it is not effective or useful anymore. Helping participants realize that ambivalence is common can be essential to helping them get unstuck.
  • Explore the risks of changing. High-risk behavior is common in the lives of many teens with co-occurring disorders. Paradoxically, these teens are often risk avoidant. As Prochaska, Norcross and DiClemente noted in 1994, change “threatens our very identity and asks us to relinquish our way of being.” This is dangerous stuff for anyone, but for stuck teens, it can feel especially risky. Helping them make lasting change requires exploring the risks involved.
  • Foster self-efficacy. Albert Bandura wrote that self-efficacy is “the belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations.” In other words, it is a person’s belief in his or her ability to succeed. Teens with low self-efficacy avoid challenging tasks, focus on negative outcomes and quickly lose confidence in their ability to be successful. They have very little interest in attempting to change.
  • Disrupt rigid thinking habits. Teens with co-occurring disorders typically exhibit all-or-nothing thinking, catastrophize, deny having problems and blame others. These rigid thinking patterns reinforce their ambivalence. Resolving ambivalence requires them to think between the extremes. Traditional cognitive behavioral approaches identify these thinking patterns as irrational, erroneous and maladaptive. I prefer the term thinking habits, because habits can be changed.
  • Address existential concerns. Irvin Yalom identified four “givens” that define an existential perspective to psychotherapy: death, meaninglessness, freedom and isolation. Professional helpers sometimes shy away from these existential concerns, especially when working with adolescents. However, these givens are very much present in the lives of teens and can contribute significantly to both stuckness and ambivalence. Acknowledge these givens and explore them with participants.

Become trauma-informed

The Substance Abuse and Mental Health Services Administration defines trauma-informed care as “an approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives.” Trauma-informed care includes the use of carefully developed approaches that reduce the likelihood of retraumatizing participants while integrating safety, trustworthiness, choice, collaboration and connection into all interactions.

Studies show that as many as 75 percent of teens in treatment for substance use disorders have experienced some form of traumatic stress. This occurs when an individual is exposed to a potentially traumatizing event or situation that overwhelms his or her ability to cope. Traumatic stress can be caused by a one-time experience or complex trauma, which can be defined as the experience of multiple traumatic events. Traumatic stress can lead to PTSD, a severe anxiety disorder that develops after exposure to traumatic stress. PTSD is a clinical diagnosis that requires the presence of specific symptoms, such as nightmares about the traumatic event, avoidance of stimuli associated with the event, increased arousal and hypervigilance. Regardless of whether they meet the diagnostic threshold for PTSD, teen trauma survivors often exhibit the following:

  • Hyperarousal: Survivors can become extremely vigilant about their surroundings and often experience high levels of anxiety, which leads to sleep problems, trouble concentrating, feeling constantly on guard or being easily startled.
  • Intrusion: Memories, flashbacks, and nightmares can continue long after the original traumatic exposure. Additionally, survivors sometimes unintentionally reenact aspects of the trauma. For example, teen survivors often engage in highly risky behaviors.
  • Constriction: Attempts to avoid intrusion frequently result in survivors withdrawing from the world both physically and emotionally. Agoraphobia, substance use, limited social interactions and dissociation are a few examples of constriction.

When an individual has both a substance use disorder and traumatic stress, we usually assume that the trauma led to using the substance. However, substance use often leads to trauma exposure — or further exposure. In addition, pre-existing mental health challenges and a variety of other factors can increase the likelihood of trauma exposure. Whether trauma leads to drug use, drug use leads to trauma or a more complex scenario is present, substance-abusing survivors often find themselves perpetually stuck.

Even though risky behavior is evident in the lives of most substance-abusing teens, and especially those with trauma histories, these youth are frequently risk adverse, with their risky behaviors serving as ineffective attempts to avoid risk or distractions from their past trauma. Some adolescent survivors are so obsessed with safety that they resort to substances and other maladaptive methods in an effort to find it. Still other teens lead lives so constricted that they barely participate in life. According to Judith Herman, in all these cases, trauma has “cast the victim into a state of existential crisis” in which all choices likely lead to even further stuckness.

Create connectedness

Edward Hallowell wrote that connectedness “is a sense of being a part of something larger than oneself. It is a sense of belonging, or a sense of accompaniment. It is that feeling in your bones that you are not alone. … Connectedness is my word for the force that urges us to ally, to affiliate, to enter into mutual relationships, to take strength and to grow through cooperative behavior.”

For teens with co-occurring disorders, this sense of connectedness is typically missing. I believe that isolation exacerbates all life problems, so I strongly propose that the first step toward ensuring a valuable therapeutic experience is helping participants move toward increased connectedness. In clinical settings, we can focus on two types of connectedness: group cohesion and therapeutic alliance.

Group cohesion: It seems to me that groups should be part of the treatment plan for any teen with co-occurring disorders. That said, for change to happen in groups, a strong sense of cohesion is essential. We can help achieve group cohesion by remembering this simple formula: Cohesion = Shared Fun + Safety.

When working in groups, it is essential that we create safe spaces. This includes physical, emotional and social safety. We can create a sense of safety by modeling what we expect. That means being consistent and reliable, treating participants and co-facilitators in a welcoming manner and ensuring that groups are fully inclusive.

Some treatment approaches seem to assume that participants are fragile, hopelessly damaged or completely dysregulated. Fun activities and laughter have no place is such approaches. That’s a shame. Shared fun activities build connectedness between group members and provide valuable opportunities to practice interpersonal skills. In addition, the use of fun and games helps alter negative preconceived notions of treatment, provides entry points for less verbal participants and helps teens reauthor their stories to include a world where laughter is the norm.

Therapeutic alliance: Numerous studies show that a strong therapeutic alliance is the most important indicator of positive outcomes when working with teens. When we take time to foster a strong alliance by genuinely embracing our participants’ real motivators, we stop being an adversary and become an ally. This allows us to gently challenge the ambivalence, thinking habits and other roadblocks that keep participants stuck.

Edward Bordin wrote that a strong therapeutic alliance is composed of three elements: a positive bond between the therapist and participant, agreement regarding the tasks of treatment and agreement about the goals of treatment. In other words, there is congruence between the participant and the therapist. It seems to me that there also exists a need for transparency. Here are a few ideas for this:

  • Explain what you’re doing as a counselor. Take time to explain the theory behind your therapeutic approaches. In addition, explain to the teen what you hope to achieve by asking a particular question or assigning a specific homework task. This not only increases transparency but also improves buy-in.
  • Remember that relationships are reciprocal. We expect participants to be honest. They should get the same from us. Don’t disclose excessive amounts of personal information, but do answer questions that have been sincerely asked. Be genuine and model openness.
  • Use concurrent documentation. Before ending individual sessions, write your progress note. Then have the participant read the progress note and write his or her own summary of the session. This may seem a bit clumsy at first, but in my experience, most participants quickly embrace the process.

Addiction as an attachment disorder 

Substance abuse specialists familiar with attachment theory invariably report an inverse relationship between substance use disorders and healthy interpersonal attachments. In traditional treatment, unhealthy interpersonal attachments are generally considered the result of addiction. There is no doubt that heavy substance abuse is likely to exert a negative influence on relationships. However, there is mounting evidence that insecure attachment styles are risk factors for problematic substance use.

There are two basic concepts that are important for us to consider. First, if we don’t have opportunities to observe caregivers engaging in effective emotional regulation, we may resort to substances in an effort to manage uncomfortable feelings. Second, if we don’t connect to other people in meaningful, emotionally satisfying ways, we will find something else to fill that void.

Andrew referred to this void as a black hole made of all colors and tried to fill it with alcohol, drugs and significant acting-out behaviors. Other teens try to fill their voids with gangs, gambling, food, sex or video games. When we slow down and meet participants where they are at, we are able to help them get unstuck and start the change process so that they can see all the colors, not just black.

 

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

David Flack is a licensed mental health counselor, chemical dependency professional and child mental health specialist. He lives in the Seattle area and has worked for the past dozen years exclusively with teenagers who have co-occurring disorders. He has special interests in the comorbidity of substance use and trauma in adolescents, the use of experiential learning in clinical settings and the unique challenges faced by LGBTQ teens. Contact him at david@davidflack.com.

Letters to the editorct@counseling.org

 

 

Falling short of perfect

By Laurie Meyers

This past December, a major pop culture event occurred for which millions of people had been waiting longer than three decades: Star Wars: Episode VII was released. Finally, the story from 1983’s Return of the Jedi was continuing. Many fans reserved tickets two months in advance, while others camped out in line overnight to be part of the audience for the first of the film’s showings. Individuals active on social media reasoned that it was essential to see this latest installment of the Star Wars series as soon as possible to avoid tripping over spoilers.

As with any work of art, people held widely divergent views of the film. In print and online — particularly on social media — passionate discussions were held on virtually every facet of the new movie, but one of the most frequently broached topics involved actress Carrie Fisher. People weren’t usually talking about how Fisher’s character, Princess Leia, was now a general or how great it was to see one of the original characters in the newest film or even the quality of Fisher’s performance though. Instead, the comments most frequently referred to her graying hair and extra weight. The overall sentiment was that Fisher was not aging “well.”

At the same time, no significant accompanying discussion took place about Harrison Ford’s (Han Solo’s) graying hair or Mark Hamill’s (Luke Skywalker’s) prodigiously grizzly beard. Instead, the refrain heard throughout social media was: What happened to the princess in the gold bikini?! (For those who have somehow managed to resist the force of the original Star Wars trilogy, Fisher — as Princess Leia — had two scenes in Return of the Jedi in which she was held prisoner while dressed in a gold-colored leather and metal bikini. The image of Fisher in the costume has become iconic.)

As Fisher herself said in a 2011 blog post discussing her decision to become a spokesperson for the weight loss company Jenny Craig: “You know, I swear when I was shooting those films, I never realized I was signing an invisible contract to stay looking the exact same way for the rest of my existence.”

Fisher’s “invisible contract” is representative of the expectations that women face in American society today: to remain young and beautiful forever, to work harder to be considered equal to men (and yet be paid less) and to be a perfect daughter, mother and wife or partner — all while doing the majority of the housework, child rearing and caregiving. Despite the significant strides women continue to make toward equality, societal expectations still lead many women to think that they can (and should) “have it all.” But that picture is acutely unrealistic, say counselors.

“Having it all means being able to fulfill multiple expectations simultaneously — the perfect appearance, perfect relationships, perfect mother and perfect career,” says Laura Hensley Choate, a licensed professional counselor (LPC) who has written extensively about women’s and girls’ issues. “It means being perfect according to societal standards for each of these roles, but even if this were possible, it also means achieving them all simultaneously.”

The problem, counselors say, is that these standards are perniciously presented to women not just as goals that can be achieved but as expectations that must be met. And when women fall short of these standards, they often view their unsuccessful attempts as personal failures rather than as an understandable inability to meet unreasonable expectations. This perspective can cause feelings of frustration, inadequacy and shame and, in some cases, lead to more serious problems.

“These expectations are so unreasonable and unattainable, and much of it is out of an individual’s control,” comments Vanessa McLean, an LPC from Richmond, Virginia, whose specialties include women’s issues. “It is easy to see how women become plagued with anxiety, self-doubt and negative cognitions that can easily spiral into anxiety disorders or depression.”

By identifying and countering these harmful societal influences, counselors want to help women separate self-image from societal expectations — and perhaps even start changing and setting the expectations themselves.

Chasing eternal youth and beauty 

Throughout much of history, women were valued only for their beauty and fertility, says Choate, a member of the American Counseling Association. Although these qualities are no longer the sole sources of a woman’s worth, youth and beauty are still the most valued, she continues, and once a woman ages and those qualities are diminished, she loses value. In contrast, Choate says, research has shown that the characteristics most prized in men — wealth, power and status — increase with age, meaning that men generally gain value as they age. This disparity is evident in popular culture, particularly in films, which frequently pair young women with much older men, but not vice versa, she notes.

In society at large, this translates into an internalized mandate for women to fight against aging by any means necessary: products, diets, surgery and so on, says Choate, a professor of counseling education at Louisiana State University. Although we live in a youth-obsessed society, the pressure Branding-Images_Falling-Shortis mostly one-sided, she notes. “Men do not feel this same pressure. Certainly not to the same extent that women do,” Choate says.

The youthful ideal that women are supposed to maintain is in itself unrealistic, McLean says. “It isn’t just attractiveness that is the ideal but an obsession with physical perfection,” she explains. “Perfect hair, perfect skin, perfect body, perfect teeth. … And the message is not only geared to young single women but to all women.”

“Women now have equal rights and opportunities to pursue education and careers,” McLean continues, “but if you consider the message that mainstream media send, both overtly and covertly, the message is still that women’s primary value is sex, [which equals] physical attractiveness.”

Working more for less

Women have largely seized the opportunity to pursue advanced education and careers, but on a societal level, their contributions in the workplace are not as highly valued as those of men — not just symbolically but also literally, experts contend.

According to a 2014 study by the U.S. Census Bureau, the median annual salary for women is 79 percent that of the median annual salary for men. That’s 79 cents for every dollar a man makes. A 2015 comparison by the U.S. Department of Labor measuring weekly salaries found that women make 81 cents for every dollar that men make. “Women often feel more pressure in the workplace to perform, simply to get equitable recognition and pay,” McLean says.

Many women’s wages are affected by factors such as maternity leave and child care, as are their career trajectories, which are often linked to making better wages, says Nadine Hartig, an associate professor and chair of the Department of Counselor Education at Radford University in Virginia. Beyond the physical demands of pregnancy, giving birth and raising children, women are often confronted with choices related to balancing their work and life roles. These are choices that men generally do not have to make, Hartig points out. Even if a woman’s husband or partner assumes some of the child-rearing and household responsibilities, the bulk of those responsibilities will typically still fall on the woman, says Hartig, a member of ACA.

Hartig notes that she made a career choice herself because of the demands of motherhood. “I chose not to go into a tenure track right away mostly because I thought it would kill me to do that at the same time as raising children,” she says.

Many women wrestle with the challenge of how or if to try balancing motherhood and work, knowing that the decisions they make could mean delaying or even derailing a career. Women are sometimes judged negatively for taking time away from work, even for maternity leave, but they are also susceptible to being judged for returning to work as quickly as possible and continuing to pursue their careers, note Hartig and Choate.

When a woman who is a mother seeks a promotion, her dedication to her children may be questioned, along with her ability to get the work done, says Hartig, an LPC who also maintains a small private practice. “This can be done in really insidious ways, with comments such as, ‘I’m concerned you won’t have enough time for your family [if given the promotion].’ Generally, men do not face this same kind of judgment. No one questions a man’s commitment as a father if he takes a promotion.”

McLean says that when parenting and household duties are factored in, research has shown that women perform 50 percent more daily work than men.

“The reality is that working mothers still tend to serve as ‘managers’ of the home,” agrees Choate. “They are the ones who keep up with the schedules, the tasks that keep the household running, the doctor’s appointments, the school needs. And while research shows that fathers do help out, it is the mothers who tend to assign the tasks to keep everything on schedule.”

“So, the mothers have to manage the home tasks — which of course take a great deal of mental energy for planning and can lead to worrying — while fathers tend not to carry this burden with them,” Choate continues. “And the societal expectation is that a good mother will keep the family’s schedule flowing seamlessly. If things don’t run well in the home, the expectation is that the mother is not doing her part well. And for single mothers, this pressure is even greater because they are not only the managers of the home, but they also have to carry out all of the tasks with very little help or support.”

Sadly, for many women, the harshest critics they face are themselves, Choate says. They try to have it all and then feel like failures when they can’t achieve the impossible. In essence, she says, “having it all” boils down to “figuring out a way to look young, thin and beautiful, be home with the kids as much as possible, be a superstar at work, have lots of successful friendships, have a blissful romantic relationship, have a perfectly decorated, always clean home [and] cook fresh, organic meals daily.”

Breaking free of the mold 

Choate says counselors can help their female clients uncover the unrealistic expectations they are operating under. “What are the actual standards they hold up for themselves in order to feel they are a success? Actually putting these expectations into words is the first step in helping to change them,” she says. “Where did they learn these expectations? How did they come to internalize these expectations? Did they learn them from parents? Teachers? Coaches? Popular media? Whose approval are they seeking?”

Once a client realizes she is responding to outside forces rather than considering options that might be right for her, the counselor can help her identify ways of creating a healthy balance that fits her life, Choate says. The counselor should have the client ask herself what makes sense for her given her personal strengths and resources.

“This will look different for everyone,” Choate says. “What are realistic and meaningful goals that respect self-care and balance versus living up to a never-ending treadmill of others’ expectations? Helping our clients separate the difference between societal ‘shoulds’ versus what each client actually wants for herself will be very freeing for her.”

In Choate’s book Girls’ and Women’s Wellness: Contemporary Counseling Issues and Interventions, published by ACA, she talks about strategies couples can use to strike a balance in household duties. Rather than trying to decide how to divide tasks exactly 50-50, she suggests that couples talk about particular duties that each partner prefers. For instance, one might prefer folding laundry to vacuuming, or washing dishes rather than taking the trash out. Couples should also talk about who will keep track of items such as bill paying, appointments and other deadlines. The most important goal is for both partners to be satisfied with the division of labor, Choate says. It is also important for partners to be flexible enough to temporarily take on more or less responsibility when needed, she adds, such as one partner tackling extra household tasks when the other partner has a project that requires extra hours.

Hartig also helps her clients re-examine the stereotypes they have been taught, particularly as they relate to body image. “I believe the first step is assessing where clients’ narratives about their bodies began,” she explains. “For example, was the client told she was fat by a parent, or did the client gain a significant amount of weight and feel differently about his or her body? Identifying the struggles a client has about his or her body is important to begin working toward self-acceptance. Often, a negative body image is indicative of feelings of inadequacy and shame. Working on these feelings can lead clients to finding peace with their bodies.”

“Some of the ways that we work with clients on self-acceptance is to explore the negative self-talk they experience and where this self-talk originated,” Hartig continues. “Coaches, parents, teachers and friends all can have an immense impact on self-talk. Counteracting this self-talk with CBT [cognitive behavior therapy] can be very helpful. Creating a new narrative about the client’s self and body is also helpful. For example, a client who can say ‘My body is strong and my body helped me escape some pretty hard situations’ is on the road to appreciating her body.”

Hartig also notes the importance of counselors being aware that negative societal messages about appearance and body image are even greater for women who are not white or heterosexual. “Women of color face even greater assaults on a positive body image [because] our culture has an ideal that is rarely inclusive of all women — or people,” she says. “Women who identify as lesbian or bisexual are also often marginalized and misunderstood with regard to body image.”

“Internalized self-loathing is a natural consequence of media and other outlets that do not embrace the beauty of diversity and realness of people,” Hartig says. “Understanding these issues specific to different cultural groups is key to helping clients with body image issues.”

McLean uses brain-based psychoeducation to help women understand why they feel they need to meet society’s unrealistic expectations. For instance, she explains that humans are hard-wired to seek social approval, so it is normal for people to want to conform. McLean then helps clients to understand their own expectations and fears and to recognize and reframe cognitive distortion. She encourages women to explore how to balance their lives around their personal values rather than around social expectations.

Hartig likes to use narrative therapy to examine her clients’ struggles with the expectations they feel they need to meet. As she listens to clients’ stories, she finds it particularly important to note losses — for example, dreams or plans a woman may have had to let go of in one part of her life, such as her career, to attend to an aspect in another domain, such as family.

For instance, Hartig had a client who had decided not to have a second baby because she wanted to pursue tenure. However, after achieving tenure, she didn’t find it particularly satisfying and felt that she had given up the chance to have another child for nothing. It was important for the woman to grieve this loss, Hartig says.

Hartig encourages clients to grieve such losses by helping them develop rituals for letting go. This might involve a client writing a letter to herself and then burning or shredding it, releasing balloons, journaling or even holding a “funeral” for what was lost. The funeral ritual might include gathering pictures or symbols of what the woman lost, putting them in a box and burying them.

Once the client is ready, Hartig helps her to “reimagine and recreate,” building a narrative around what she wants her life to be going forward and how she can make that happen.

“For some, writing this plan down makes sense and is helpful,” Hartig says. “This can take the form of a ‘letter from your future self’ or free writing/journaling about hopes for the future. This process can also be done in the therapy session, as some clients do not respond well to written homework. I think the crucial element is to gently invite the client to envision a life that looks different than what … she originally planned, once the grief has dissipated.”

Until society rejects the picture of perfection that is “having it all,” counselors can play an important role in helping women strike a balance that allows them to have what they need.

 

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To contact the individuals interviewed for this article, email:

 

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Related reading:

See Laurie Meyers’ companion article to this piece, “Girls feeling pressure to be ‘sexy, famous and perfect’,” for more on how counselors can help young girls defy societal stereotypes and pressures.

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

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